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HomeMy WebLinkAboutCOM 0099.001 2020-2022 a v, Yi a k. Mitchell D.Roth *:t Deanna S. Sako Ainyor Director • rE,F "� Steven A.Hunt Deputy Director County of Hawaii Finance'Department 25 Aupuni Street,Suite 2103 • Hilo,Hawaii 96720 (808)961-8234 • Fax(808)961-8569 February 12, 2020 Maile Medeiros David, Council Chair and Members of the Hawai`i County Council '`7, Hawaii County Council 25 Aupuni Street Hilo, Hawaii 96720 at Re: Nonprofit Grant Applications • - . In compliance with Chapter 2, Article 25 of the Hawai`i County Code, I am submitting the M " applications from eligible nonprofit organizations for your review and appropriation of funds for the FY 2021 - 22 nonprofit grant program. The applications are submitted as received from the applicants except that applications submitted double-sided have been copied to single-sided and staples and paper clips have been removed for easy scanning. There may be some applications with "blank" pages or other additional pages within them, which we left in-tact, so the page numbering is not changed. Also enclosed is a list of these eligible organizations with the name of their program and the amount they are requesting from the County. Should you have any questions, please feel free to call Lisa Tada at 961-8489. A Deanna S. Sako Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants (Note: Due to their size, the applications are not made a part of the duplicate copies of this document, but are available for viewing in the Office of the County Clerk, and online by clicking "Our County," then "Council Records" at http://hawaiicounty.gov.) Comm. N 1�• Ref.To: TSSSG Hawaii County is an Equal Opportunity Employer and Provider Ref. Date FEB 1 2 2021 NONPROFIT GRANT APPLICANTS FOR FY2021-22 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. ',.Numerical' ‘'-_,Sort ' ..--' ` ' ' ''' ".' ;" ''__- -2; ''- ' '' ' 1 '' ''''' „7 ' -'''-'' -'. Order ; -Order "-- ' ' ',. ' —',ORGANIZATION NAME''-',;. ',','" '''.-,-',:-, :. ,-- PROGRAM NAME ' .."- ' - '; ''''' ' , REQUESTED; 11 1 After-School All-Stars Hawaii After-School at Kali High&Pahala Elementary 12,000.00 14 2 After-School All-Stars Hawaii After-School at Kea'au Middle School 12,000.00 13 3 After-School All-Stars Hawai'i After-School at Pahoa High&Intermediate 12,000.00 12 4 After-School All-Stars Hawai'i After-School at Waiakea Intermediate 12,000.00 234 5 'Aha Panana Leo,Inc. Halau Lamak0 295,349.00 232 6 Alex&Duke De Rego Foundation Water Safety&Ocean Awareness Education 62,671.00 141 7 Aloha Club of Hilo Hale'Oluea Clubhouse 45,800.00 32 9 Aloha Independent Living Hawaii [independent Living Program 10,000.00 33 10 Aloha Independent Living Hawai'i Transportation 10,000.00 Excellence in ALS Care Initiative-Equipment Loan Program and 29 12 ALS'Ghana of Hawaii Direct Assistance Grants 21,000.00 28 13 ALS'Ghana of Hawai'i Excellence in ALS Care Initiative-Professional Care Management 46,000.00 86 15 American National Red Cross,The Disaster Preparedness&Response in Hawaii County 50,000.00 90 17 Arc of Kona Health and Wellness for All Abilities 22,400.00 81 18 Arts&Sciences Center ASC Community Education Services 105,000.00 42 19 Big Island Mediation,Inc.DBA West Hawai'i Mediation Center Community Mediation 15,000.00 41 20 Big Island Mediation,Inc.DBA West Hawaii Mediation Center Peer Mediation and Youth Conflict Resolution Education 15,000.00 BIISC Invasive Species Early Detection and Rapid Response 153 22 Big Island Resource Conservation&Development Council Program 30,000.00 155 23 Big Island Resource Conservation&Development Council Education in Experiential Learning on Tropical Plants 10,000.00 156 24 Big Island Resource Conservation&Development Council Mauna Kea Watershed Alliance 20,000.00 154 25 Big Island Resource Conservation&Development Council Nutrition Grown Farming Educational Program 30,000.00 158 38 Boy Scouts of America Hawai'i Island Scouting Program-Scoutreach 51,780.00 Community Meal Support for Income-Challenged Youth,Kupuna, 196 39 Boys&Girls Club of the Big Island and Families 100,000.00 Daily Transport Services of Critical Needs Resources for Income- 193 40 Boys&Girls Club of the Big Island Challenged Youth,Kupuna and Families 50,000.00 Critical Needs Resources,Academic Support,Youth Development 191 41 Boys&Girls Club of the Big Island,Hilo Club Programming for Income-Challenged Youth 70,000.00 Critical Needs Resources,Academic Support,Youth Development 198 42 Boys&Girls Club of the Big Island,Kea'au Club Programming for Income-Challenged Youth 70,000.00 Critical Needs Resources,Academic Support,Youth Development 199 43 Boys&Girls Club of the Big Island,Kealakehe Club Programming for Income-Challenged Youth 70,000.00 Critical Needs Resources,Academic Support,Youth Development 195 44 Boys&Girls Club of the Big Island,Ocean View Club Programming for Income-Challenged Youth 70,000.00 Critical Needs Resources,Academic Support,Youth Development 197 45 Boys&Girls Club of the Big Island,Pahala Club Programming for Income-Challenged Youth 70,000.00 Critical Needs Resources,Academic Support,Youth Development 192 46 Boys&Girls Club of the Big Island,Pahoa Club Programming for Income-Challenged Youth 70,000.00 Critical Needs Resources,Academic Support,Youth Development 194 47 Boys&Girls Club of the Big Island,Ulu Wini Club Programming for Income-Challenged Youth 70,000.00 122 48 Brantley Center Inc. Job Skills Development Program 30,000.00 120 49 Bridge House,Inc. Care Coordination 12,000.00 119 50 Bridge House,Inc. Clean&Sober Living Program 25,000.00 121 51 Bridge House,Inc. Vocational Skills Building Program 20,000.00 52 52 Center for Getting Things Started Ono-licious Youth Cooking Contest-Local Food Promotion 22,300.00 94 53 Child&Family Service East Hawai'i Alternatives to Violence 35,000.00 93 54 Child&Family Service ' East Hawaii Domestic Abuse Shelter 30,000.00 91 55 Child&Family Service West Hawaii Alternatives to Violence 46,000.00 NONPROFIT GRANT APPLICANTS FOR FY2021-22 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 92 56 Child&Family Service West Hawaii Domestic Abuse Shelter 30,000.00 Project Permanence:Guardianships and Adoptions for At-Risk 209 57 Children's Law Project of Hawai'i,The Kids 20,000.00 208 58 Children's Law Project of Hawaii,The Victim Options for Investigation,Child Empowerment and Safety 20,000.00 157 59 Daniel R.Sayre Memorial Foundation,The The Daniel R.Sayre Memorial Foundation Tax ID 26-1097159 69,016.00 143 61 East Hawai'i Cultural Council EHCC Exhibition and Lecture Series,FY2021-22 10,075.00 53 62 Effective Planning&Innovative Communication,Inc. HI HOPES Initiative HI HOPES Match 10,000.00 131 63 Family Support Services of West Hawaii Fatherhood Initiative 35,000.00 130 64 Family Support Services of West Hawai'i Healthy Keiki 24,000.00 167 71 Food Basket,Inc.,The HAMAKUA Emergency Food Program 5,000.00 169 72 Food Basket,Inc.,The KA'-)Emergency Food Program 9,000.00 165 73 Food Basket,Inc.,The NORTH HILO Emergency Food Program 3,000.00 170 74 Food Basket,Inc.,The NORTH KOHALA Emergency Food Program 1,000.00 163 75 Food Basket,Inc.,The NORTH KONA Emergency Food Program 10,000.00 168 76 Food Basket,Inc.,The PUNA Emergency Food Program 25,000.00 166 77 Food Basket,Inc.,The SOUTH HILO Emergency Food Program 42,000.00 164 78 Food Basket,Inc.,The SOUTH KOHALA Emergency Food Program 2,000.00 171 79 Food Basket,Inc.,The SOUTH KONA Emergency Food Program 3,000.00 87 80 Friends of Big Island Drug Court,Inc.(FOBIDC) Friends of Big Island Drug Court 10,000.00 44 84 Friends of the Children's Justice Center of East Hawaii Special Needs,Enhancement,Support,Education&Training 11,300.00 50 85 Friends of the Palace Theater Annual Musical 22,000.00 51 86 Friends of the Palace Theater Hawaiian Roots Festival of Talent 15,000.00 49 87 Friends of the Palace Theater Youth Theater Program 15,000.00 56 88 Full Life Adult Day Health Community Learning and Art Center 10,000.00 55 89 Full Life Associated Costs for Self-Determined Living 6,000.00 57 90 Full Life Empowering Creativity-Pua Na Pua and Abled Hawai'i Artists 9,000.00 7 91 Girls Scouts of Hawai'i Hawai'i Island Girl Scout Leadership Experience 40,000.00 145 92 Going Home Hawai'i Hawaii Island Going Home Consortium 32,751.00 107 93 Goodwill Industries of Hawaii,Inc. Career Services 30,000.00 108 94 Goodwill Industries of Hawaii,Inc. Ho'olana Educational and Arts Program 40,000.00 106 95 Goodwill Industries of Hawaii,Inc. Ola I Ka Hana Youth Program 30,000.00 132a 96 Grassroots Community Development Group Hawai'i Youth Business Center:Media Literacy 7,400.00 132b 97 Grassroots Community Development Group Hawai'i Youth Business Center:Ola'a Skatepark Phase II 20,000.00 132 98 Grassroots Community Development Group La'au'Ohana Ekolu 9,000.00 117 101 Habitat for Humanity Hawai'i Island Nanawale Builds:Kilauea Recovery 50,000.00 16 104 Hale Kipa,Inc. Kai Like Program 7,500.00 118 105 Hale 0 Hawai'i:Housing and Lands Enterprise of Hawai'i County Hale 0 Hawai'i Capacity Building 31,000.00 109 106 Hamakua Harvest,Inc. Demonstration Orchard at Hamakua Harvest,Inc. 22,500.00 ' 83a 107 Hamakua Youth Foundation,Inc. Hamakua Youth Center 20,000.00 83 108 Hamakua Youth Foundation,Inc. Intersession Gardening Program 10,000.00 NONPROFIT GRANT APPLICANTS FOR FY2021-22 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 84a 109 Hamakua Youth Foundation,Inc. Keiki Multicultural Awareness Program 20,000.00 84 110 Hamakua Youth Foundation,Inc. Opio(Teen)Program 10,000.00 74 111 Hawai'i Children's Action Network(HCAN) Hawai'i Diaper Bank(a fiscally sponsored program of HCAN) 25,000.00 177 112 Hawaii County Economic Opportunity Council East Hawaii Nutrition Transportation 195,469.59 178 113 Hawai'i County Economic Opportunity Council East Hawaii Seniors Farmers'Market 37,784.75 179 114 Hawaii County Economic Opportunity Council Kokua 0 Puna 250,000.00 180 115 Hawaii County Economic Opportunity Council Mass Transit East Hawaii 120,022.17 176 116 Hawaii County Economic Opportunity Council Mass Transit West Hawai`i 120,022.17 175 117 Hawai'i County Economic Opportunity Council West Hawai'i Nutrition Transportation 195,469.59 174 118 Hawaii County Economic Opportunity Council West Hawaii Seniors Farmers'Market 37,784.75 186 120 Hawaii Institute of Pacific Agriculture(HIP Ag) 'Aina Lessons:Farm to Fork in Hawaii 16,100.00 188 121 Hawaii Institute of Pacific Agriculture(HIP Ag) Keiki to Kupuna Care Bags 45,887.00 Kohala Lalawai:Growing Kohala Farmers,A Farm to School 187 122 Hawaii Institute of Pacific Agriculture(HIP Ag) Project 46,500.00 211 124 Hawai'i Island Home for Recovery,Inc.HIHR Consolidated HIHR Permanent Supportive Housing Programs 39,000.00 210 125 Hawai`i Island Home for Recovery,Inc.HIHR HIHR Kitchen&Pantry Food Outreach Programs 20,000.00 212 126 Hawai'i Island Home for Recovery,Inc.HIHR HIHR Transitional Housing Program 39,000.00 200 128 Hawai'i Rise Foundation Family Assessment Center-Ulu Wini 38,000.00 Malama Na Keiki After-School and Weekend BackPack Food 202 129 Hawai'i Rise Foundation Program 30,000.00 203 130 Hawai'i Rise Foundation Rise-UP Domestic Violence Housing Program 30,000.00 201 131 Hawai'i Rise Foundation Together We Can 187,000.00 43 132 Hawai'i Society of OB/GYN Hawaii County OB/GYN Resident Program 78,400.00 82 133 Hawai'i Wildlife Center Native Wildlife Services 10,000.00 217 135 Hilo Community Players 2021 Fall Musical 13,500.00 219 136 Hilo Community Players 44th Annual Shakespeare in the Park Festival 10,500.00 221 137 Hilo Community Players Kid-Shakes Presents 4,000.00 222 138 Hilo Community Players LGBTQIA+Outreach 5,100.00 218 139 Hilo Community Players Na Mea Hawaii Theatre 11,000.00 220 140 Hilo Community Players Rising Stars 8,300.00 Planning for a Community Agriculture-Based Resilience Hub in 173 142 Ho'ulu Lahui Puna 45,240.00 85 143 Holualoa Village'Ohana Coffee&Art Stroll 7,000.00 104 144 Holualoa Village'OhanaMusic&Light Festival 5,000.00 226 145 Homeless Task Force dba 808 Homeless Task Force Fab Rehab Program 44,440.00 223 146 Homeless Task Force dba 808 Homeless Task Force Outreach and Engagement,"A Vision For You"Program 144,850.00 225 147 Homeless Task Force dba 808 Homeless Task Force Return to Work Program 69,440.00 224 148 Homeless Task Force dba 808 Homeless Task Force Safe Haven Options Program:Housing and Return Home 85,350.00 110 149 Ho'ola Veteran Services Growing Veterans:Incubator Farm 11,450.00 235 150 HOPE Services Hawai'i,Inc. Permanent Supportive Housing 20,000.00 236 153 HOPE Services Hawai'i,Inc. Prevention Assistance 20,000.00 135 154 Hospice of Kona Maluihi Grief Center-Community Bereavement Program 25,000.00 NONPROFIT GRANT APPLICANTS FOR FY2021-22 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 213 158 Hui Malama Ola Na'Oiwi KOkua Hall Specialty Para Transit 45,600.00 215 159 Hui Malama Ola Na'Oiwi Ladies'Night Out 9,250.00 214 160 Hui Malama Ola Na'Oiwi Physical Fitness Program-Makahiki Games 38,519.00 40 161 Hui Pono Holoholona Low Cost Spay/Neuter Clinics 51,000.00 45 167 Innovations Public Charter School Foundation Na Kalai Ola-Life Navigators-Wellness Program 10,000.00 111 170 Japanese Cultural Center of Kona Land Acquisition Due Diligence Work 22,000.00 6 171 Kamuela Philharmonic Orchestra Society Elementary School Music Education Program 10,000.00 63 172 Keaukaha One Youth Development Ho`.la Hou-Hawaiian Warriorship Program 25,000.00 I 61 173 Keaukaha One Youth Development HOkualaka'i Restoration Project 25,000.00 64 174 Keaukaha One Youth Development Junior Lifeguarding Program 25,000.00 62 175 Keaukaha One Youth Development PISCES-VEX IQ Robotics Program 25,000.00 59 176 Keaukaha One Youth Development RISE 21st Century After School Program 25,000.00 65 177 Keaukaha One Youth Development Temple Children Collaboration Project 25,000.00 60 178 Keaukaha One Youth Development Youth Paddling Program 25,000.00 10 179 Kohala Animal Relocation And Education Service(KARES) Accessible Veterinary Support for Family Pets 68,000.00 160 181 Ku'ikahi Mediation Center Community Conflict Prevention&Resolution Services 25,000.00 159 182 Ku'ikahi Mediation Center Youth Peer Mediation Program 15,000.00 102 183 Kupu Hawaii Island Kupu ina Corps 2.0 500,000.00 78 184 La'i'Opua 2020 Ho'okahua-Business Basics 40,000.00 183 185 Laupahoehoe Train Museum 'Aina-Based Education Program for Youth and Community 20,000.00 182 186 Laupahoehoe Train Museum The Honeybee Education Program 10,000.00 3 187 Little Big Tots Foundation Scholarship Awards 20,000.00 136 188 LOkahi Treatment Centers,Inc Adolescent Substance Abuse Treatment Programs 35,000.00 137 189 LOkahi Treatment Centers,Inc Adult Substance Abuse Treatment Programs 50,000.00 138 190 LOkahi Treatment Centers,Inc Anger Management Treatment Programs 30,000.00 139 191 LOkahi Treatment Centers,Inc Domestic Violence Intervention Treatment Programs 35,000.00 140 192 LOkahi Treatment Centers,Inc Health&Fitness Program 25,000.00 189 198 Mala'ai Hawai'i Island School Garden Network 54,000.00 190 199 Mala'ai The Culinary Garden of Waimea Middle School 55,000.00 4 204 Mental Health Kokua Case Management 15,000.00 5 205 Mental Health Kokua Residential Rehabilitation 15,000.00 89 206 Na'alehu Main Street,Inc. Haumana A'o'Oihana'0 Ka'u 31,000.00 88 207 Na'alehu Main Street,Inc. Raised Garden Initiative 35,000.00 72 208 Neighborhood Place of Puna Family Resource Center 25,000.00 147 209 North Kohala Community Resource Center Kohala Cares-Weekly Food Drive 10,260.00 146 210 North Kohala Community Resource Center Kohala Unupa'a Mauka to Makai Summer Camp 5,000.00 148 211 North Kohala Community Resource Center North Kohala Golf Park 5,400.00 115 212 '0 Ka`u Kakou Family Fun Fest 8,000.00 116 213 '0 Ka`u Kakou Ka'0 Veterans'Day Celebration 3,000.00 r NONPROFIT GRANT APPLICANTS FOR FY2021-22 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 114 214 'O Ka`0 Kakou Kali Sanitation 9,000.00 99 216 Pacific Tsunami Museum Tsunami Education through Distance Learning 21,866.00 30 217 PETFIX Spay and Neuter Spay and Neuter Clinics 10,000.00 233 218 POhaha I Ka Lani Mahina'Ai 50,000.00 46 219 Project Vision Hawaii Better Vision for Keiki 25,000.00 47 220 Project Vision Hawaii HiEHiE-Hawai'i Island 25,000.00 48 221 Project Vision Hawaii Hui for Health-Hawai'i Island 25,000.00 98 222 Puna Canoe Club Outrigger Paddling Program 0.00 124 225 Salvation Army Family Intervention Services,The Cultural-Based Program-Island-Wide 20,000.00 123 226 Salvation Army Family Intervention Services,The Independent Living Skills Program-East Hawaii 10,000.00 126 227 Salvation Army Family Intervention Services,The Kea'au Prevention and Outreach Programs 10,000.00 127 228 Salvation Army Family Intervention Services,The Pahoa Prevention and Outreach Programs 10,000.00 1 125 229 Salvation Army Family Intervention Services,The Project TLP Hilo 10,000.00 113 230 Services for Seniors Inc Services for Seniors 75,000.00 128a 231 Society for Kona's Education&Art(SKEA) Art Camps for Children and Teens 11,000.00 128b 232 Society for Kona's Education&Art(SKEA) South Kona Workshops and Events 10,000.00 58 233 Special Olympics Hawaii Special Olympics East Hawaii 15,000.00 54 234 Special Olympics Hawaii Special Olympics West Hawaii 10,000.00 2 235 Teach for America Hawaii Hawaii Island Initiatives 40,000.00 1 238 Volunteer Legal Services Hawaii Hawaii County Pop-Up Legal Clinics 17,500.00 76 239 West Hawaii Community Health Center,Inc.(WHCHC) Dental Expansion for Low Income in South Kona 20,000.00 75 240 West Hawaii Community Health Center,Inc.(WHCHC) Outreach to Vulnerable Populations Program 20,000.00 77 241 West Hawaii Community Health Center,Inc.(WHCHC) Street Medicine-Homeless Outreach Program 20,000.00 Total 6,596,847.02 Note:,The.following eppircants did.not meet one or more application requirements(disqualified) 152 8 Aloha'Ilio Rescue Big Island Spay and Neuter Program 30,000.00 172 11 Aloha Performing Arts Company dba Aloha Theatre Mainstage Productions 20,000.00 73 14 American Lung Association,The Hawaii County Tobacco Cessation and Education Program 16,677.31 95 16 American National Red Cross,The Disaster Preparedness&Response in Hawai'i County 50,000.00 184 21 Big Island Music&Arts Academy Voices of the Youth 10,000.00 26 26 Big Island Substance Abuse Council Community Outreach 10,000.00 25 27 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment 95,000.00 18 28 Big Island Substance Abuse Council Hawaii Island Health&Wellness Center-Hilo 50,000.00 22 29 Big Island Substance Abuse Council Hawaii Island Health&Wellness Center-Kea'au 50,000.00 23 30 Big Island Substance Abuse Council Hawaii Island Health&Wellness Center-Provider Training 50,000.00 19 31 Big Island Substance Abuse Council Intensive Case Management Services 20,000.00 21 32 Big Island Substance Abuse Council Ola Kino Health Fitness Program 20,000.00 24 33 Big Island Substance Abuse Council Po'okela Vocational Training Program 75,000.00 NONPROFIT GRANT APPLICANTS FOR FY2021-22 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 27 34 Big Island Substance Abuse Council Therapeutic Living and Clean and Sober Program 100,000.00 17 35 Big Island Substance Abuse Council West Hawai'i-Dual Diagnosis Treatment 100,000.00 20 36 Big Island Substance Abuse Council Youth Services Program 150,000.00 105 37 Big Island Wellness Solutions Big Island Wellness Solutions=Community Outreach 6,700.00 Safe Pets Safe Kids: Link Between Domestic Violence and Animal 34 60 Domestic Violence Hurts Animals and People Abuse 16,300.00 Kanaka 0 Kupuna's Men of PA'A;'Aina-Based Recovery in North 149 65 Feed Hawaii Kohala 29,775.00 151 66 Feed Hawaii Kanaka 0 Puna's Men of PA'A in Puna 27,995.00 150 67 Feed Hawai'i Kohala Keia 2.0 15,125.00 69 68 Five Mountains Hawai'i dba Kipuka o ke Ola Healthcare Outreach and Education for Underserved Populations 11,000.00 Mental Health and Primary Care Services for Underserved 67 69 Five Mountains Hawai'i dba KTpuka o ke Ola Populations 30,000.00 68 70 Five Mountains Hawaii dba KTpuka o ke Ola Preventative and Holistic Health Services 15,000.00 129 81 Friends of KPPCS dba West Hawai'i Community Kitchen West Hawai'i Community Kitchen Value-Added Program 35,575.00 71 82 Friends of the Children of West Hawai'i,Inc. Ready Center Initiative 100,000.00 70 83 Friends of the Children of West Hawai'i,Inc. Youth Leadership Alliance 25,000.00 79 99 Green Will Conservancy Inc,The Hui Mana'o 21,250.00 Malama Pono Program:Green Will Professional Learning 80 100 Green Will Conservancy Inc,The Community 19,000.00 31 102 Halau E Hulali Mai I Ka La Spreading Hawaiian Culture 10,000.00 100 103 Halau Hula Ka Makani Hall'Ala 0 Puna Hawaiian Cultural Center 15,000.00 15 119 Hawai'i Filmmakers Collective Hawai'i Filmmakers Collective Big Island Chapter 5,000.00 8 123 Hawaii Island Adult Care,Inc. Adult Day Care 100,000.00 142 127 Hawai'i Oil Seed Producers(HOSPRO) Developing a Biofuel Stem Program for Hawaii County 16,600.00 181 134 Heart Ranch Heart Ranch 18,000.00 9 141 Ho'ola Na Pua Services for At-Risk Youth&Victims of Trafficking 75,000.00 237 151 HOPE Services Hawaii,Inc. Permanent Supportive Housing 20,000.00 238 152 HOPE Services Hawai'i,Inc. Permanent Supportive Housing 20,000.00 134 155 Hospice of Kona,Inc./Hospice of Kona Foundation Nakamaru Hale 50,000.00 133 156 Hospice of Kona,Inc./Hospice of Kona Foundation Volunteer 15,000.00 University of Hawai'i Internal Medicine Residency Program Rural 66 157 Hui Kahu Mama Health Elective(UHIMRP) 41,200.00 228 162 Humanity Hale Abuse Prevention&Diversity Training 76,000.00 231 163 Humanity Hale Art Therapy 96,000.00 227 164 Humanity Hale Hawaiian Arts 62,000.00 229 165 Humanity Hale Individual and Group Therapy 62,000.00 230 166 Humanity Hale Life Skills 96,000.00 96 168 Island of Hawaii YMCA,The Family Visitation Center(FVC) 78,000.00 Youth Services Program-New Horizons Summer-Child Care 97 169 Island of Hawai'i YMCA,The Program 15,000.00 112 180 Kona Coffee Cultural Festival 50th Kona Coffee Cultural Festival 25,000.00 39 193 Maika'i Health Corporation Building Public Health Infrastructure Within Primary Care 45,595.00 35 194 Maika'i Health Corporation Clinical Pharmacist Provider Program 55,279.00 37 195 Maika'i Health Corporation COVID-19 Vaccine Response 65,149.00 NONPROFIT GRANT APPLICANTS FOR FY2021-22 • Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. Expanding Alternative Access to Health Care Services in East 38 196 Maika'i Health Corporation Hawaii 82,440.00 36 197 Maika'i Health Corporation Pharmacy-Public Health Initiative 50,420.00 205 200 Malamalama Waldorf School Hawaiian Arts and Culture 10,900.00 207 201 Malamalama Waldorf School Hui'Ano Ano Parent/Child Development Program 11,500.00 204 202 Malamalama Waldorf School Puna Arts in the Park 10,650.00 206 203 Malamalama Waldorf School Puna Off The Streets And Aftercare 9,880.00 103 215 '0 Maku'u Ke Kahua Community Center 'O Maku'u Ke Kahua Community Center 100,000.00 "Food Taco"Program-Food Security through Raised Garden 216 223 Pure KNF Foundation Beds 11,000.00 185 224 Recycle Hawai'i Zero Waste Support Services 0.00 101a 236 Uhane Pohaku Na Moku 0 Hawaii Ho'okupu Hula No Ka'u Cultural Festival 11,200.00 101 237 Uhane Pohaku Na Moku 0 Hawai'i Mo'olelo Traditions of a Mo'o Lawai'a Phase II 10,000.00 162 242 YWCA of Hawai'i Island Developmental Preschool 20,000.00 161 243 YWCA of Hawaii Island Sexual Assault Support Services(SASS) 30,000.00 Total 2,619,210.31 • After-School All-Stars Hawaii After-School at Ka`u High & Pahala Elementary 1 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka'u High and Pahala Elementary Agency Director: Paula Fitzell, President and CEO Phone No.: (8C)19 73d— 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 1523 Kalakaua Avenue, Suite 200-202 Address: City,sT,Zip Honolulu, HI 96826 Facility Address: Address: Program operates at Ka'u High and Pahala Elementary Address: 96-3150 Pikake Street City,ST,zip Pahala, HI 96777 Email Address: pfitzell@asashawaii.org Fax No.: (Kid 355— 0232 Accountant/CPA: Glen Takamatsu Phone No.: (Ng 5311— 7323 Firm (if applicable): Hee & Ching CPAs LLC Mailing Address: Address: 201 Merchant Street, Suite 1830 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua [' North Kona ❑South Hilo ❑ North Kohala ['South Kona ❑ North Hilo ❑South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns Youth ❑Victims of Crimes 111 Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka`u High and Pahala E� 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 - for 3 schools $3,770 $6,625 2.Agency Mission Statement: After-School All-Stars Hawaii (ASAS Hawaii) provides after-school and summer programs that keep children safe and help them achieve in school and in life. Each year, hundreds of Hawaii students gain access to sports, enrichment and academic opportunities through ASAS Hawaii programs. We target middle school youth who face one or more challenges indicating they are "at-risk," such as low household income, poor academic performance, poor attendance record and lack of access to after-school opportunities. For the 2019-20 school year, 2,081 students participated in ASAS Hawaii after-school programs prior to Covid-19 school closures. Our partner schools bear the Title I designation, indicating high numbers of low-income families. Many have high numbers of students with special education needs or English language learning needs. Generally,these schools fall below state averages on standardized test scores, high school completion and median income levels, and have higher incidences of chronic absenteeism and behavior referrals. 3. Program Description: When public schools shut down in March 2020 due to Covid-19, few people predicted that most Hawaii classrooms would remain closed through 2020 and into 2021. It is unclear if regular school operations will resume in the 2020-21 school year or if remote learning will continue, even up to and including the 2021-22 school year.The efficacy of remote learning has been inconsistent, as educators grapple with virtual platforms and systems.There will likely be severe negative repercussions to children's academic growth, engagement and social development. Looking ahead, ASAS Hawaii is mitigating learning loss through free after-school and summer programs. We have maintained programming through the changing landscape of Covid-19. Through virtual and/or in-person formats, students attend classes, go on field trips, learn from guest speakers, engage in hands-on activities and participate in sports and arts enrichment activities. By providing additional learning time and academic support every day, we are working with school partners to combat the negative implications of Covid-19 for low-income students. Our programs continue to be provided in virtual or in-person formats for the upcoming school year. 4.Total Budget& Position Count: Total Program Budget: $72,000 Total Program Position Count: 5 Total Agency Budget: $2,272,900 Total Agency Position Count: 96 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka`u High and Pahala Eli 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate 21st Century Community Learning Grant(80%of award/ASAS Hawaii is a subgrantee) 60,000 TOTAL: 60,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ASAS Hawaii programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding. ASAS Hawaii activities are largely supported through government grants, which comprise 76%of revenue.The 21st Century Community Learning Center program is a significant resource; however, these grants can be inconsistent and unreliable. For multi-year awards, the annual amounts are reduced by 80%and contractors must make up the difference in program costs.Three of our Hawaii County schools have reduced awards for FY22. In addition to government grants, about 9%of revenue is comprised of foundation grants from sources including Mclnerny Foundation and Kamehameha Schools. Due to Covid-19, our annual fundraiser was canceled this year (and may be canceled in 2021), adding further pressure to the operating budget. In spite of funding difficulties, ASAS Hawaii has been operating in Hawaii public schools since 2009 with excellent results. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal is to mitigate Covid-19 learning loss for socially and economically disadvantaged middle school students. ASAS Hawaii is working with educators to expand academic support, offer targeted tutoring, provide positive role models and keep students engaged in learning through after-school and summer programs. The following objectives will indicate success in this endeavor. 1. 50 ASAS participants in the grant period, as evidenced by the number of students who attend virtual or in-person programs at this school. 2. 50% of ASAS participants attend regularly, which is defined as 15 days or more per semester. 3. 80% of ASAS participants indicate programs help them achieve in school via written survey. 4. 100%of ASAS participants have access to daily homework help and academic supports in core areas of language arts, math and science. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka`u High and Pahala Eb 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of participants in the grant period 50 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including language arts,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 4,000 66,000 9,000 Professional Fees 500 Operations Supplies 2,225 5,000 3,000 Equipment Other: Staff Training 500 Other: Other: Other: Other: TOTAL 6,225 72,000 12,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 . County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka`G High and Pahala Eli 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. 'kes ll + CEO I /2I I2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka'u High and Pahala Ej 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka'u High and Pahala Eli 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. //2/2oz/ Signature of Authorized Person Date Paula Fitzell, President and Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Ka`u High and Pahala Eli 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants in the grant period 50 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including reading,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 9,000 Professional Fees Operations Supplies 3,000 Equipment Other: Other: Other: Other: Other: TOTAL 12,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2021-2022 Page 8 of 8 After-School All-Stars Hawaii After-School at Kea'au Middle School 2 . County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kea'au Middle School Agency Director: Paula Fitzell, President and CEO Phone No.: (8Q19 73e— 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 1523 Kalakaua Avenue, Suite 200-202 Address: City,ST,zip Honolulu, HI 96826 Facility Address: Address: Program operates at Kea'au Middle School Address: 16-565 Kea'au-Pahoa Road City,ST,Zip Kea'au, HI 96749 Email Address: pfitzell@asashawaii.org Fax No.: (8Q60350— 0232 Accountant/CPA: Glen Takamatsu Phone No.: (8Q11531@— 7323 Firm (if applicable): Hee & Ching CPAs LLC Mailing Address: Address: 201 Merchant Street, Suite 1830 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kea'au Middle School 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 - for 3 schools $4,900 $6,625 2. Agency Mission Statement: After-School All-Stars Hawaii (ASAS Hawaii) provides after-school and summer programs that keep children safe and help them achieve in school and in life. Each year, hundreds of Hawai'i students gain access to sports, enrichment and academic opportunities through ASAS Hawaii programs. We target middle school youth who face one or more challenges indicating they are "at-risk," such as low household income, poor academic performance, poor attendance record and lack of access to after-school alternatives. For the 2019-20 school year, 2,081 students participated in ASAS Hawaii after-school programs prior to Covid-19 school closures. Our partner schools bear the Title I designation, indicating high numbers of low-income families. Many have high numbers of students with special education needs or English language learning needs. Generally,these schools fall below state averages on standardized test scores, high school completion and median income levels, and have higher incidences of chronic absenteeism and behavior referrals. 3. Program Description: When public schools shut down in March 2020 due to Covid-19, few people predicted that most Hawaii classrooms would remain closed through 2020 and into 2021. It is unclear if regular school operations will resume in the 2020-21 school year or if remote learning will continue, even up to and including the 2021-22 school year.The efficacy of remote learning has been inconsistent, as educators grapple with virtual platforms and systems.There will likely be severe negative repercussions to children's academic growth, engagement and social development. Looking ahead, ASAS Hawaii is mitigating learning loss through free after-school and summer programs. We have maintained programming through the changing landscape of Covid-19. Through virtual and/or in-person formats, students attend classes, go on field trips, learn from guest speakers, engage in hands-on activities and participate in sports and arts enrichment activities. By providing additional learning time and academic support every day, we are working with school partners to combat the negative implications of Covid-19 for low-income students. Our programs continue to be provided in virtual or in-person formats for the upcoming school year. 4.Total Budget& Position Count: Total Program Budget: $112,000 Total Program Position Count: 8 Total Agency Budget: $2,272,900 Total Agency Position Count: 96 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kea'au Middle School 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate 21st Century Community Learning Grant(80%of award/ASAS Hawaii is a subgrantee) 100,000 TOTAL: 100,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ASAS Hawaii programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding. ASAS Hawaii activities are largely supported through government grants, which comprise 76%of revenue.The 21st Century Community Learning Center program is a significant resource; however, these grants can be inconsistent and unreliable. For multi-year awards,the annual amounts are reduced by 80%and contractors must make up the difference in program costs.Three of our Hawaii County schools have reduced awards for FY22. In addition to government grants, about 9%of revenue is comprised of foundation grants from sources including Mclnerny Foundation and Kamehameha Schools. Due to Covid-19, our annual fundraiser was canceled this year (and may be canceled in 2021), adding further pressure to the operating budget. In spite of funding difficulties, ASAS Hawaii has been operating in Hawaii public schools since 2009 with excellent results. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal is to mitigate Covid-19 learning loss for socially and economically disadvantaged middle school students.ASAS Hawaii is working with educators to expand academic support, offer targeted tutoring, provide positive role models, and keep students engaged in learning through after-school and summer programs. The following objectives will indicate success in this endeavor. 1. 250 ASAS participants in the grant period, as evidenced by the number of students who attend virtual or in-person programs at this school. 2. 50%of ASAS participants attend regularly, which is defined as 15 days or more per semester. 3. 80%of ASAS participants indicate programs help them achieve in school via written survey. 4. 100%of ASAS participants have access to daily homework help and academic supports in core areas of language arts, math and science. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kea'au Middle School 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of participants in the grant period 250 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including language arts,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 • PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 4,000 101,500 9,000 Professional Fees 500 Operations 1,000 Supplies • 2,225 8,000 3,000 Equipment Other: Staff Training 1,000 Other: Other: Other: Other: TOTAL 6,225 112,000 12,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kea'au Middle School 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: x❑ If no conflicts exist, check here. Q'- o I / al IMI Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii g Y Program Name: After-School at Kea'au Middle School 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii g Y Program Name: After-School at Kea'au Middle School 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 40,11(-- I1 II flallaoal Signature of Authorized Person Date Paula Fitzell, President and Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 1 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kea'au Middle School 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants in the grant period 250 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including reading,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 9,000 Professional Fees Operations Supplies 3,000 Equipment Other: Other: Other: Other: Other: TOTAL 12,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2021-2022 Page 8 of 8 After-School All-Stars Hawai'i After-School at Pahoa High & Intermediate 3 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Intermediate Agency Director: Paula Fitzell, President and CEO Phone No.: (81O 73d— 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 1523 Kalakaua Avenue, Suite 200-202 Address: City,ST,Zip Honolulu, HI 96826 Facility Address: Address: Program operates at Pahoa High and Intermediate Address: 15-3038 Pahoa Village Road City,ST,zip Pahoa, HI 96778 Email Address: pfitzell@asashawaii.org Fax No.: (8Q )35a— 0232 Accountant/CPA: Glen Takamatsu Phone No.: (8Q61153a— 7323 Firm (if applicable): Hee & Ching CPAs LLC Mailing Address: Address: 201 Merchant Street, Suite 1830 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona [' North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑� Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 { County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Intermed 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 - for 3 schools $4,650 $7,125 2. Agency Mission Statement: After-School All-Stars Hawaii (ASAS Hawaii) provides after-school and summer programs that keep children safe and help them achieve in school and in life. Each year, hundreds of Hawai'i students gain access to sports, enrichment and academic opportunities through ASAS Hawaii programs. We target middle school youth who face one or more challenges indicating they are "at-risk," such as low household income, poor academic performance, poor attendance record and lack of access to after-school alternatives. For the 2019-20 school year, 2,081 students participated in ASAS Hawaii after-school programs prior to Covid-19 school closures. Our partner schools bear the Title I designation, indicating high numbers of low-income families. Many have high numbers of students with special education needs or English language learning needs. Generally, these schools fall below state averages on standardized test scores, high school completion and median income levels, and have higher incidences of chronic absenteeism and behavior referrals. 3. Program Description: When public schools shut down in March 2020 due to Covid-19, few people predicted that most Hawaii classrooms would remain closed through 2020 and into 2021. It is unclear if regular school operations will resume at all schools in the 2020-21 school year or if remote learning will continue, even up to and including the 2021-22 school year.The efficacy of remote learning has been inconsistent, as educators grapple with virtual platforms and systems.There will likely be severe negative repercussions to children's academic growth, engagement, and social development. Looking ahead,ASAS Hawaii is mitigating learning loss through free after-school and summer programs. We have maintained programming through the changing landscape of Covid-19. Through virtual and/or in-person formats, students attend classes, go on field trips, learn from guest speakers, engage in hands-on activities and participate in sports and arts enrichment • activities. By providing additional learning time and academic support every day, we are working with school partners to combat the negative implications of Covid-19 for low-income students. Our programs continue to be provided in virtual or in-person formats for the upcoming school year. 4.Total Budget& Position Count: Total Program Budget: $100,000 Total Program Position Count: 6 Total Agency Budget: $2,272,900 Total Agency Position Count: 96 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 Countyof Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Intermed 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate 21st Century Community Learning Grant(80%of award I ASAS Hawaii is a subgrantee) 88,000 TOTAL: 88,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ASAS Hawaii programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding. ASAS Hawaii activities are largely supported through government grants, which comprise 76% of revenue.The 21st Century Community Learning Center program is a significant resource; however,these grants can be inconsistent and unreliable. For multi-year awards,the annual amounts are reduced by 80%and contractors must make up the difference in program costs.Three of our Hawaii County schools have reduced awards for FY22. In addition to government grants, about 9%of revenue is comprised of foundation grants from sources including Mclnerny Foundation and Kamehameha Schools. Due to Covid-19, our annual fundraiser was canceled this year (and may be canceled in 2021), adding further pressure to the operating budget. In spite of funding difficulties, ASAS Hawaii has been operating in Hawaii public schools since 2009 with excellent results. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal is to mitigate Covid-19 learning loss for socially and economically disadvantaged middle school students. ASAS Hawaii is working with educators to expand academic support, offer targeted tutoring, provide positive role models, and keep students engaged in learning through after-school and summer programs. The following objectives will indicate success in this endeavor. 1. 100 ASAS participants in the grant period, as evidenced by the number of students who attend virtual or in-person programs at this school. 2. 50%of ASAS participants attend regularly, which is defined as 15 days or more per semester. 3. 80%of ASAS participants indicate programs help them achieve in school via written survey. 4. 100%of ASAS participants have access to daily homework help and academic supports in core areas of language arts, math and science. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii • Program Name: After-School at Pahoa High and Intermed 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of participants in the grant period 100 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including language arts,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 4,500 93,000 9,000 Professional Fees 500 Operations • 1,000 Supplies 2,625 5,000 3,000 Equipment Other: Staff Training 500 Other: Other: Other: Other: TOTAL 7,125 100,000 12,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Intermed 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: x❑ If no conflicts exist, check here. 'Alen /C co dal l /202/ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Intermed 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Intermed 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. / /2//202/ Signature of Authorized Person Date Paula Fitzell, President and Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High and Interme6 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants in the grant period 100 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including reading,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 9,000 Professional Fees Operations Supplies 3,000 Equipment Other: Other: Other: Other: Other: TOTAL 12,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2021-2022 Page 8 of 8 After-School All-Stars Hawai`ii After-School at Waiakea Intermediate 4 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate Agency Director: Paula Fitzell, President and CEO Phone No.: (81j 73d— 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 1523 Kalakaua Avenue, Suite 200-202 - Address: City,,ST,zip Honolulu, HI 96826 Facility Address: Address: Program operates at Waiakea Intermediate School Address: 200 W. Puainako Street City,ST,Zip Hilo, HI 96720 Email Address: pfitzell@asashawaii.org Fax No.: (80111356— 0232 Accountant/CPA: Glen Takamatsu Phone No.: (Ng 7323 Firm (if applicable): Hee & Ching CPAs LLC Mailing Address: Address: 201 Merchant Street, Suite 1830 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona 0 North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes I Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor [' Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 - for 3 schools $0 $7,125 2.Agency Mission Statement: After-School All-Stars Hawaii (ASAS Hawaii) provides after-school and summer programs that keep children safe and help them achieve in school and in life. Each year, hundreds of Hawai'i students gain access to sports, enrichment and academic opportunities through ASAS Hawaii programs. We target middle school youth who face one or more challenges indicating they are "at-risk," such as low household income, poor academic performance, poor attendance record and lack of access to after-school alternatives. For the 2019-20 school year, 2,081 students participated in ASAS Hawaii after-school programs prior to Covid-19 school closures. Our partner schools bear the Title I designation, indicating high numbers of low-income families. Many have high numbers of students with special education needs or English language learning needs. Generally, these schools fall below state averages on standardized test scores, high school completion and median income levels and have higher incidences of chronic absenteeism and behavior referrals. 3. Program Description: When public schools shut down in March 2020 due to Covid-19, few people predicted that most Hawaii classrooms would remain closed through 2020 and into 2021. It is unclear if regular school operations will resume at all schools in the 2020-21 school year or if remote learning will continue, even up to and including the 2021-22 school year.The efficacy of remote learning has been inconsistent, as educators grapple with virtual platforms and systems.There will likely be severe negative repercussions to children's academic growth, engagement, and social development. Looking ahead, ASAS Hawaii is mitigating learning loss through free after-school and summer programs. We have maintained programming through the changing landscape of Covid-19. Through virtual and/or in-person formats, students attend classes, go on field trips, learn from guest speakers, engage in hands-on activities and participate in sports and arts enrichment activities. By providing additional learning time and academic support every day, we are working with school partners to combat the negative implications of Covid-19 for low-income students. Our programs continue to be provided in virtual or in-person formats for the upcoming school year. 4.Total Budget& Position Count: Total Program Budget: $264,000 Total Program Position Count: 11 Total Agency Budget: $2,272,900 Total Agency Position Count: 96 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate 21st Century Community Learning Grant(ASAS Hawaii is a subgrantee) 252,000 TOTAL: 252,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ASAS Hawaii programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding. ASAS Hawaii activities are largely supported through government grants, which comprise 76%of revenue.The 21st Century Community Learning Center program is a significant resource; however, these grants can be inconsistent and unreliable. For multi-year awards, the annual amounts are reduced by 80% and contractors must make up the difference in program costs.Three of our Hawaii County schools have reduced awards for FY22. In addition to government grants, about 9%of revenue is comprised of foundation grants from sources including Mclnerny Foundation and Kamehameha Schools. Due to Covid-19, our annual fundraiser was canceled this year (and may be canceled in 2021), adding further pressure to the operating budget. In spite of funding difficulties, ASAS Hawaii has been operating in Hawai'i public schools since 2009 with excellent results. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal is to mitigate Covid-19 learning loss for socially and economically disadvantaged middle school students. ASAS Hawaii is working with educators to expand academic support, offer targeted tutoring, provide positive role models, and keep students engaged in learning through after-school and summer programs. The following objectives will indicate success in this endeavor. 1. 300 ASAS participants in the grant period, as evidenced by the number of students who attend virtual or in-person programs at each school. 2. 50%of ASAS participants attend regularly, which is defined as 15 days or more per semester. 3. 80% of ASAS participants indicate programs help them achieve in school via written survey. 4. 100%of ASAS participants have access to daily homework help and academic supports in core areas of language arts, math and science. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of participants in the grant period 300 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including language arts,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 4,500 204,000 8,000 Professional Fees 1,000 Operations 2,000 Supplies 2,625 9,500 4,000 Equipment Other: Staff Training 1,000 Other: Daily Transportation 45,000 Other: Miscellaneous 1,500 Other: Other: TOTAL 7,125 264,000 12,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: x❑ If no conflicts exist, check here. Peesioairr Icea //2//2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 ///2o2/ Signature of Authorized Person Date Paula Fitzell, President and Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Waiakea Intermediate , 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants in the grant period 300 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in learning new things 2 Number of Sports Showdown events provided for the complex area 2 Participants have access to academic support in core areas including reading,math and science achieved Percentage of participants who indicate programs help them achieve in school via written survey 80% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 8,000 Professional Fees Operations Supplies 4,000 Equipment Other: Other: Other: Other: Other: TOTAL 12,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2021-2022 Page 8 of 8 %ha Punana Leo, Inc. Halau Lamaku 5 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:'Aha Punana Leo, Inc. Pro ram Name: Halau Lamaku g Agency Director: Ka`iulani Laeha Phone No.:(808 ) 935 —4304 Contact Person: Ka`iu Kimura Phone No.:(808 ) 932 —8920 Mailing Address: Address: 96 Puuhonu PI Address: City,ST,Zip Hilo, Hawaii, 96720 Facility Address: Address: 600'Imiloa PI. Address: City,ST,Zip Hilo, HI, 96720 Email Address: lesliek@hawaii.edu Fax No.: (808 ) 969 —9748 Wikoff&Combs(auditor)**accounting is done in-house** Accountant/CPA: Phone No.:(808 ) 791 —1414 Firm (if applicable): Mailing Address: Address: 1001 Bishop Square,ASB Tower City,ST,Zip Honolulu, HI, 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑ Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑ South Kona ❑i. North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) i❑ Educational concerns i❑Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: 'Aha Punana Leo, Inc. Program Name: Halau Lamaku 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $3,000 n/a n/a 2. Agency Mission Statement: E ho'oulu i ke kaia'olelo Hawaii no ko Hawai`i nei i mau aku `o Hawaii he`aina aloha. Drive and inspire change to ensure a living Hawaiian language in Hawai'i and beyond. 3. Program Description: The`Aha Punana Leo(`APL), a non-profit organization and licensed preschool childcare provider, in partnership with the `Imiloa Astronomy Center('Imiloa), proposes to offer Halau Lamaku:Keiki Enrichment Program. Halau Lamaku is a Spring/Summer/Fall'21-Spring'22 education enrichment childcare program for keiki spanning grades K-5:This program was created in light of the ongoing disruption in K-12 school schedules due to the COVID-19 pandemic.This program partnership has and continues to meet urgent childcare needs for families while also providing their children with access to innovative culture-and place-based STEM learning experiences in a safe and welcoming environment. The program is offered Monday through Friday from 8-3pm at the`Imiloa facility and will commence as follows: 2 21: 6 weeks •July-August 0 •October 2021:1 week • March 2022: 1 week **Activities will be offered on Saturdays at'Imiloa for family education and engagement** The'APL's vision is for the Hawaiian language to once again be spoken fluently in Hawai`i. We operate twelve preschools throughout the state that are conducted entirely through Hawaiian.According to the statistical report on Detailed Languages Spoken at Home in the State of Hawaii conducted by Hawaii Data Center and the Department of Business, Economic Development, and Tourism(2016), Hawaiian is the most frequently spoken second language in the County of Hawai'i, giving us the highest percentage of speakers in the state, with the majority of speakers living in East Hawaii. 'APL will partner with`Imiloa to deliver a childcare program that will expand our current capacity to serve Hawaiian-speaking families within East Hawaii, while also encouraging non-Hawaiian speaking families to use the Hawaiian language through 'Imiloa's culture-and place-based programming. 4. Total Budget& Position Count: Total Program Budget: $754,000 Total Program Position Count: 30 Total Agency Budget: $5,499,131 Total Agency Position Count: 77 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `Aha Punana Leo, Inc. Program Name: Halau Lamaku 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Matson Foundation $5,000 Ama`Olukai Foundation $10,000 Participant Registration Fees $45,280 Japan Foundation for the Promotion of Astronomy $9,415 Pending: Hawaii Community Foundation $50,000 TOTAL: $119,695 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: `Imiloa is actively seeking other grants and support to further extend the Halau Lamaku program. These include private grants, public grants, and donations. We also charge a nominal registration fee for participants. Imiloa was also recently licensed as a center-based childcare operator by the State of Hawaii, Department of Human Services. This designation allows for qualifying, low-income families to apply for childcare subsistence from State-and other-programs like Childcare Connection and Open Doors in order to support registration fees for program entry. 7. Program Objectives Using County Nonprofit Grant Program Funds: Halau Lamaku will be offered at the Imiloa facility on the UH-Hilo campus,for 8 weeks total to support the 2021-2022 school year. Based on responses from the community and school surveys that we conducted in school year 2020-2021, we recognize there is an urgency to support working families with their need for childcare, as well as for providing culture-, place-STEM-based programs to further supplement their childrens development. With the loss of thousands of classroom learning hours lost due to the COVID-19 pandemic, families and teachers are seeking creative and safe enrichment supplements that can provide for engaging learning opportunities for students. In response to this input, `Imiloa proposes the following program components:(1)a Monday thru Friday full-day place- based educational enrichment program that complies with county, state, and national COVID-19 safety guidelines during summer and intercession breaks, (2)tutoring and supplemental learning support services supplemented with computers and WIFI for formal academic distance learning requirements, and (3)expansion and enhancement of safe indoor and outdoor learning spaces in compliance with CDC protocols for social distancing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `Aha Punana Leo, Inc. Program Name: Halau Lamaku 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) In-program and post-program evaluations(student and family) 500 surveys completed #Learner hours supported through Halau Lamaku 2500 hours #Curriculum units produced 24 units(2x month) #Career Connected Learning lectures 12 lectures(lx month) Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 604,000 236,000 Professional Fees Operations Supplies 150,000 25,350 Equipment Other: Administrative Fee 34,044 Other: Other: Other: Other: TOTAL $754,000 $295,349 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `Aha Punana Leo, Inc. Program Name: Halau Lamaku 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council ro The Mayor QI The Managing Director Di The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■n If no conflicts exist, check here. 4"-- 6 #1 i /it- -1,,,,091t; -/"Z.-- e-e--./e. .7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: 'Aha POnana Leo, Inc. Program Name: Halau Lamaku 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: `Aha Punana Leo, Inc. Program Name: Halau Lamaku 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. /2 _Ci`X/1-1 "f /' IGS` ' r of c2 / Signature of Authorized Person Date Fire041,- Title/Position 4rTitle/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: 'Aha Punana Leo, Inc. Program Name: Halau Lamaku 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result In-program and post-program evaluations (student & family) 500 surveys # Learner hours supported through Halau Lamaku 2500 hours # Curriculum units produced 24 units # Career Connected Learning lectures 12 lectures TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 236,000 Professional Fees Operations Supplies 25,350 Equipment Other: Administrative Fee 34,044 Other: Other: Other: Other: TOTAL 295,349 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Alex & Duke De Rego Foundation Water Safety& Ocean Awareness Education 6 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Alex & Duke De Rego Foundation Program Name: Water Safety & Ocean Awareness Education Agency Director: Shirley De Rego Phone No.:(808 )960 —4889 Contact Person: Shirley De Rego Phone No.:(808 )960 —4889 Mailing Address: Address: P.O. Box 2128 Address: City,ST,Zip Kamuela, Hawaii 96743 Facility Address: Address: Alexander& Duke De Rego Foundation Address: 65-1206 Mamalahoa Hwy Unit 2-104 city,sr,zip Kamuela, Hawaii 96743 Email Address: alexanddukederego@gmail.com Fax No.: ( ) — Accountant/CPA: Keahikaaiohelo Kanahele Phone No.:(808 ) 491 —5003 Firm (if applicable): Innovative Native Services LLC Mailing Address: Address: 1114 Auwae Road City,ST,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $62,671.50 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna 0 Hamakua ❑ North Kona ❑South Hilo 0 North Kohala ❑South Kona ❑ North Hilo 0 South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Alex & Duke De Rego Foundation Program Name: Water Safety & Ocean Awareness Education 1. Prior Year Award of County Nonprofit Grant Program Funds: FY18-19 FY19-20 FY20-21 N/A N/A 2.Agency Mission Statement: The Mission of the Alex& Duke De Rego Foundation is: "We are dedicated to providing the youth of Hawaii with the right skillset that will empower them with the knowledge and awareness they need to safeguard their lives and the lives of others. Even one life lost to unpreparedness near the ocean or injury-where help in providing appropriate and timely First/Aid CPR is crucial-is one life lost too many" While we can cannot always control the circumstances that surround these accidents,The Alex&Duke De ego Foundation's Water Safety&Ocean Awareness Education Program prepares our youth with the capabilitiy and knowledge to survive them. The Alex& Duke De Rego Foundation was created in 2011 in memory of Alexander and Duke;two brothers who lost their lives at young ages due to tragedies that could have been prevented with the right safety awareness education. https://www.alexanddukederegofoundation.com 3. Program Description: The Alex& Duke De Rego Foundation provides Water Safety&Ocean Awareness Education support to 6th grade Middle School students on the Island of Hawaii in South Kohala, North Kohala,and adding Hamakua Middle Schools.This is done through a two day program which consist of: Day 1. Classroom interaction with students, power point presentation/documentary that tells the story behind the program and Introduces the Water Safety&Ocean Awareness Education program to the students in their classroom environment. Day 2. A four-hour workshop,six grade classes are transported to Hapuna Beach State park on a field trip working in tandem with their physical education, health and safety curriculum. Here they get hands on learning experience through rotating interactive stations offering excercise,ocean swim, rescue techniques,ocean currents&conditions and First Aid/CPR procedures. Our program has been a success as a larger number of children are able to particapate in Water Safety Education through a school environment. 4.Total Budget&Position Count: Total Program Budget: $62,671.50 Total Program Position Count: 2 Total Agency Budget: $62,671.50 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Alex & Duke De Rego Foundation Program Name: Water Safety & Ocean Awareness Education 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Mauna Lani Resort/Fundraiser Fundraiser set for July 2021 $5,000 Hawaii Island Charity Walk Fundraiser set for May 2021 $6,000 TOTAL: $11,000 Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: Seeking additional Grant Funds: Atherton Foundation *Grant Stattion *Hawaii Island Charity Walk *Holiday Benefit Fundraiser(ADDF) *Personal Donations 7. Program Objectives Using County Nonprofit Grant Program Funds: A 2018 Senate Concurrent Resolution Bill S.C.R. No.168"urges The Department of Education to implment Ocean Water Safety Education Programs for Elementary School Student.The Center for Disease Contral and Prevention reports that from 2005-2014,there were an average of 3,536 fatal unintentional drownings, non-boating related,annually in the United State;whereas one in five people who die from drowning are children fourteen years and younger. Our objective is to reduce these numbers in Hawaii,starting within our Community working in tandem with the 6th grade Middle School students.Our program allows students hands on experience through rotating interactive stations offering: I. Physical Fitness-Stretching,Jumping Jacks, Running, Introduction to Junior Lifeguard 2. Water Safety-Ocean Currents,riptides, waves,ocean floor drop off, rocks and sea urchin's 3. Water Rescue-Simulated water rescue with paddle boards and rescue tubes 4. First Aid/CPR-Basic Wound aid, head injury,CPR Mannequin training 5. Ocean Swimming -Swim techniques,free swim time Our Instructors are certified Lifeguards and Fireman who give of their time and talents to the ADDF Program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Alex & Duke De Rego Foundation Program Name: Water Safety & Ocean Awareness Education 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Our Program is continuous every year with our target Middle Schools Surveys and Teacher reports Waimea Middle School 96 Kids Kohala Middle School 105 Parker School 67 Waikoloa Middle School 123 Kanu 0 Ka Aina Charter School 20 Honokaa Middle School 120 Attach additional pages as necessary. 9.TABLE I1: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $43,080 $43,080 Professional Fees Operations Supplies Equipment Other: Uniforms/Quick Dry Shirts $7,995 . $7,995 Other: Program Handbook& First Aid Kits $5,596.50 $5,596.50 Other: Documentary $6,000 $6,000 Other: Other: TOTAL $62,671.50 $62,671.50 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Alex & Duke De Agency Name.: Rego Foundation g �Y Program Name: Water Safety & Ocean Awareness Education 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Alex & Duke De Rego Foundation POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council - O The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: D If no conflicts exist, check here. II ' - /,, !f1, January 282021 S gnature f Authoriz t)- / pk,Nd.,e4,4-- d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 A en Name:Alex & Duke De Rego Foundation g cY Program Name: Water Safety & Ocean Awareness Education 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii: I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Alex & Duke De Rego Foundation Program Name: Water Safety & Ocean Awareness Education = Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 28, 2021 Signature of A uthorized Person Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Alex & Duke De Rego Foundation Program Name: Water Safety & Ocean Awareness Education 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 A Aha Club of Hilo Hale 'Oluea Clubhouse 7 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Club of Hilo Program Name:Hale `Oluea Clubhouse Agency Director: Mera Page, President Phone No.:(808 ) 974 —4320 Contact Person: Renee Bertolette Phone No.:(sos ) 854 —5053 Mailing Address: Address: 1045-B Kilauea Ave Address: City,sr,Zip Hilo, Hi 96720 Facility Address: Address: 1045-B Kilauea Ave Address: City,sr,Zip Hilo, Hi 96720 Email Address: thealohaclubofhilo@gmail.com Fax No.: (808 ) 933 —0533 Accountant/CPA: Ronelle Matsunami Phone No.:(808) 837 —2505 Firm (if applicable): The CPA Collective Mailing Address: Address: 711 Kapiolani Blvd Suite 1430 City,ST,Zip Honolulu, Hi 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,800.00 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑■ Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑South Kona ❑■ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑Youth ❑■ Victims of Crimes ❑ Culture and the arts ■❑Aged Victims of Health or Social Crises ❑l Needs of the poor 0 Physical/Emotional Disabilities ■❑ Public Health and Welfare of the n People and the Environment et EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale `Oluea Clubhouse 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 0 0 $13,125.00 2. Agency Mission Statement: The Clubhouse mission is to offer comprehensive psychosocial rehabilitation services to adults with serious and persistent mental illness to help them . improve their abilities needed for successful reintegration into the community and to increase their quality of life.The Clubhouse provides a supportive and nurturing environment that enhances self-motivation, respect for self and others, and a desire to work.The Aloha Club of Hilo is the non-profit entity that raises funds for the provision of psychosocial rehabilitation activities for Hale Oluea Clubhouse • 3. Program Description: Hale'Oluea Clubhouse(haleolueaclubhouse.com) is a virtul and on-site(when safely open)psychosocial rehabilitation program in Hilo for adults living with severe and persistent mental illness while challenged with meeting basic needs.The Clubhouse is affiliated with Clubhouse International(https://clubhouse-intl.org/) (CI)who's mission is"Ending social and economic isolation for people with mental illness by growing the number&quality of Clubhouse rehabilitation programs world wide." Hale'Oluea Clubhouse members improve quality of life through:1) Support coping w/homelessness/securing housing.2)Opportunities to volunteer and/or secure paid employment via transitional/supported/independent employment programs, including work readiness,transportation, on-site job training, advocacy work w/employers&coverage for employee absences.3)Opportunities for on-line&travel to/participation in Clubhouse training/conferences&inclusion in the CI community. Training for both staff&members is required to obtain&maintain Clubhouse accreditation. Research shows that accredited Clubhouses are more successful in all areas of operations. 4)Support w/post-incarceration/ reintegration into the community.5)Access to low-cost nutritious meals/snacks&support w/securing supplemental food programs. 6)A work-ordered day where members use their talents to run the daily business of the Clubhouse,working along side staff in a non-judgmental/supportive environment. 7)Daily on-going participation in consensus decision-making, where all voices are heard,encouraging member participation/ownership. 8)Support in pursuing education goals,tutoring &computer literacy. 9)Social events such as virural holiday celebrations, and off-site excursions for recreational,advocacy and wellness activities. 10) Free transportation&assistance securing additional dependable transportation. 11)Access to peer groups/peer-led classes, support managing mental health symptoms/crisis& linkages to mental health case managers/psychiatrists&therapists. 12)Banking, support with financial planning/budgeting/taxes&social security/medical benefits.13)Support with mental health awareness,self-advocacy and non-profit board participation. 4.Total Budget & Position Count: Total Program Budget: $115,475.00 Total Program Position Count: *see attached Total Agency Budget: $731,988.00 Total Agency Position Count: 9 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale `Oluea Clubhouse 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate T-Shirt sales, Recycling,Thrift Store Sales $250.00 Food Sales $800.00 Donations from Individuals and organizations $1,700.00 Grants projected(other than Hawaii County) $39,000.00 Fundraising Events $2000.00 Cash On Hand (Including Restricted Grant Funds) $25,925.00 County Grant for training and training computers(Anticipated) $45,800.00 TOTAL: $115,475.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2020,our plans to increase revenues included our traditional fund-raisers(rummage sale/silent auctions, Zumba fund raisers, car washes, charity walks and 2 musical entertainment events), more grants applications and building relationships with stakeholders to grow individual and organizational donations as well as county government grants. However, when the pandemic struck the fundraisers were cancelled.Additionally, the nature of our program changed to a mostly on-line format with food delivery and occasional on-site assistance for program participants at a safe physical distance. Our training needs changed too as almost all Clubhouse international training was cancelled and moved to on- line training beginning in 2021. So, in 2020, we turned most of our efforts to increase revenue toward grant applications. We did exceptionally well in grant awards,covering essential expenses such as food, protective personal equipment, computer equipment and devices for our virtual Clubhouse program.As a virtual program our needs have changed. We now need more revenue for on-line training and programs to assist in technical support for computers and communication devices(phones and tablets)for our members so they can stay connected to the program while our physical doors are closed and as we re-open at partial capacity. We plan on raising money to cover these expenses through the Hawaii County grant. We hope to pay for more training fees and computers for training as well as applying for other grants to cover food and phones. We are also planning on-line food sales fundraisers and will continue to build relationships with stakeholders to grow individual and organizational donations. 7. Program Objectives Using County Nonprofit Grant Program Funds: Hale'Oluea Clubhouse was awarded a 3-year conditional accreditation in January, 2019. One of the conditions of this accreditation, and a standard of Clubhouse International, is that we prioritize sending staff and members to Clubhouse International training sites for important instruction, guidance and support on building and operating our Clubhouse .As stated previously, it has been documented through research that accredited Clubhouses are more successful in all areas of operations. Currently only 1 out of 9 staff have been trained and only 1 member out of a membership base of 94 has been trained.Additionally, our director has not been trained. To address our needs for training, we applied for and were awarded$13,125.00 by the County of Hawaii for FY 20-21. However, we were only able to use$1,000.00 of this money for training in the fall of 2020 due to the pandemic. We faced limits on travel, cancellation of on-site trainings and no on-line Clubhouse training available (other than one conference that many members attended on line.) Clubhouse International has now developed a comprehensive on-line training program to begin in March 2021. We plan to spend the rest of the awarded FY 20-21 funds on this on-line training. However, after these funds are spent for FY 20-21, we will still need funds to continue the training for all staff and more members, to comply with our accreditation and to achieve this key goal in 2021-2022.As most of our members do not have access to computers, we need dedicated computers for member on-line training. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale `Oluea Clubhouse 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 9 staff and 9 members able to attend(General)Clubhouse 2 week on-line training Meet accrediation Standards 1 staff and 2 members will be able to attend Employment track training. y10%eleh'n2yea's d="""°�aem°'°yme"' 2 staff and 2 members will be able to attend the Young Adults Group tramming and increse attendance of young adults by 10%within 2 years Meer Accrediaeon standardstincrease young adult attendance by 10%within 2 years members who currrently dont have computers will have increased access to technology and be able to participate In on-line training. Increase access to technology among members by 10%within 1 year Staff and members created training action plan during training. Present and implement action plan at Clubhouse. Hate'oluea Clubhouse is granted a 3 year accreditation and maintins its accreditation with continued member and staff training Be awarded and maintain 3 year accreditation Due to Training Action plan,there is an Increase members served and increase in overall attendance Increase overall attendance by 10%within 2 years Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $0.00 $0.00 $0.00 Professional Fees $2,151.79 $2800.00 Operations $20,218.36 $36,350.00 Supplies $269.45 $5,525.00 Equipment 5,339.93 $0.00 Other: (Computer Equip For On-line training for virtual Clubhouse) $0.00 $5,000.00 $5,000.00 'Salary,wages,other operating expenses are pd by auspice agency.See attached Aloha Club Flnanlcal Model Other: Other: Training Fees $1,000.00 $40,800.00 $40,800.00 Other: Capital Improvements $25,000.00 Other: TOTAL $28,979.53 $115,475.00 $45,800.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale Oluea Clubhouse 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Larry Stevens POSITION: Treasurer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor El The Managing Director • The Director of Finance �❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Fir If no conflicts exist, check here. ?, ) Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale `Oluea Clubhouse 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale Oluea Clubhouse 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. -- Signature r/Authorized Person Date Treasurer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Club of Hilo Program Name: Hale `Oluea Clubhouse 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 9 staff and 9 members able to attend(General)Clubhouse 2 week on-line training Meet accrediatlon Standards 1 staff and 2 members will be able to attend Employment track training em t/credlatlanstanaards/Increase employment by 10%within 2 years 2 staff and 2 members will be able to attend the Young Adults Group tramming and increse attendance of young adults by 10%within 2 years Mee!aneedianon Standards/increase young adult attendance by 10%within 2 years members who currently dont have computers will have increased access to technology and be able to participate in on-line training. Increase access to technology among members by 10%within 1 year Staff and members created trainingactionplan duringtrainingPresent and implement action plan at Clubhouse. Hale'oluea Clubhouse is granted a 3 year accreditation and maintlns its accreditation with continued member and staff training Be awarded and maintain 3 year accreditation Due to Training Action plan,there is an Increase members served and increase in overall attendance Increase overall attendance by 10%within 2 years TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Clubhouse International On-Line Traininig $40,800.00 Other: Computers for on-line training $5,000.00 Other: Other: Other: TOTAL $45,800.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hale 'Oluea Clubhouse Financial Model The Aloha Club of Hilo is a 501 © (3) non-profit with primary responsibility for fundraising for Hale 'Oluea Clubhouse to cover budget items that are not covered by the auspice agency, the State of Hawaii Department of Health, Adult Mental Health Division. The overall budget of the Clubhouse is $847, 463.00. 86.37% of the income for the program comes from the State of Hawaii, Adult Mental Health division, equaling $731,998.00. The remaining 13.63% is covered by the non-profit, The aloha Club of Hilo and equals$115,475.00. The State of Hawaii income covers operational expenses such as salary for staff, rent,telephones, copy machine, transportation costs including gas, oil, repairs, and other general office operating expenses. The State of Hawaii, AMHD also owns the vehicles used by the program All other costs are being covered by the Non-Profit, The Aloha Club of Hilo. Below is the Estimated Clubhouse expenditures covered by the auspice agency,the State of Hawaii,Adult Mental Health Division, Calendar Year 2019 & Calendar Year 2020 Category of monthly expenses 2019 2020 Personnel/Staff $42,139.00 $42,139.00 OPERATIING COSTS Electricity $3,500.00 $3,500.00 Lease Rental $10,901.75 $12,000.00 Telephones $80.00 $80.00 Cell phone $30.00 $270.00 Lease of Copy Machine $300.00 $300.00 Motor Vehicle Gas and Oil $1,000 $300.00 Repair and Maintenance of State Vehicles $500.00 $100.00 Office and Other Supplies $250.00 $100.00 Postage $50.00 $100.00 Janitorial supplies $120.00 $75.00 Subscriptions (Newspaper) $10.00 $10.00 Services on a Fee Bases (ASL interpreters) $2,000.00 $2,000.00 Pest treatment $52.08 $25.00 Total Cost per Month $60,932.83 $60,999.00 Total Projected Annual Cost $731,193.96 $731,988.00 I am certifying the above 2019 figures and the 2020 estimate figures as valid. Larry Stevens!Treasurer, Aloha Club of Hilo Date Aloha Independent Living Hawaii !independent Living Program 9 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name: Independent Living Program Agency Director: Roxanne Bolden Phone No.:(808 ) 497 —7996 Contact Person: Roxanne Bolden Phone No.:(808 ) 497 —7996 Mailing Address: Address: P.O. Box 283 Address: City,ST,zip Pearl City, Hawaii 96782 Facility Address: Address: 1055 Kino'ole Street Unit 202 Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: rubolden@alohailhawaii.org Fax No.: (800 ) 385 —2454 Accountant/CPA: Darrel Urn Phone No.:(808) 522 —8833 Firm (if applicable): Darrel Lim and Company, Inc. Mailing Address: Address: 81 South Hotel Street Unit 300 City,ST,zip Honolulu, Hi 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 10,000 Geographical Areas To Be Served: (One or more can be checked) Puna 0 Hamakua 0 North Kona El South Hilo ® North Kohala 0 South Kona North Hilo South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,175 $4,643 $6,875 2. Agency Mission Statement: To provide independent living programs and services to persons with disabilities living in Hawaii 3. Program Description: The concept behind independent living is the empowerment of persons with disabilities to make choices in their lives that will enhance their dignity and self-respect and provide full integration into the community as equal citizens with all the privileges and responsibilities available to them.We have two goals which is to address their rights and responsibilities and to facilitate their accomplishment 4.Total Budget& Position Count: Total Program Budget: $79,227 Total Program Position Count: 2 Total Agency Budget: $77,600 Total Agency Position Count: 15 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Title VII Part C Independent Living Services Funded by DHS under ACL $438,216 Title VII Part B Independent;Living Services Funded by OHS under DVR $290,939 County of Hawaii $5,000 Foundation Grants $5,133.00 Individual Contributions $10,000 TOTAL: $749,288.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: AILH will continue to apply for grants to help support both operational and programmatic costs. This is in addition to continually working on developing new,creative resource opportunities, including: •Federally funded grants and contracts •State-funded grants and contracts •Local government grants and contracts 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.To provide one-on-one independent living skills training to carry out their everyday living activities. 2.Provide information and referrals. 3.Provide training in landlord/tenant rights. 4.Provide attendant referrals to acquire personal assistance services 5.Provide assistance in locating affordable and accessible housing 6. Provide assistance in learning daily life skills to further independence EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Training in landlord/tenant rights 40 How to complete housing application 40 How to locate and maintain housing 40 Training in independent living skills 30 Training in legal rights and self-advocacy 100 Provide attendant referrals to acquire personal assistance services 20 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 33,408 77,827 10,000 Professional Fees Operations Supplies 683 800 Equipment Other: Training 300 500 Other: Other: Other: Other: TOTAL 34,391 79,127 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): El Member or members of the Council fa Staff appointed by a member of the Council ❑a The Mayor The Managing Director r The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 01 If no conflicts exist, check here. /7,6(; 6-)cc ,1/c r 67 ,V0,3(ignature of Authorized Person (specify title) / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Program is. Certification of Understanding (Page 1 of 2) I (we) have read and.understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify,that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name: Independent Living Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. V ao.4 Sigyature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 ........... r t .:,,.,,ww y , .�.tww�a •��v.: �,w.....,.n,v..Wi�s�raiv�. t ..a.,..-w„�smw,w,..,N ,.„m.�..r.:.xnu,rea.-,vei. 0 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Training in landlord/tenant rights 40 How to complete housing application 40 How to locate and maintain housing 40 Training in independent living skills 30 Training in legal rights and self-advocacy 100 Provide attendant referrals to acquire personal assistance services 20 TABLE II: FY 21- 22 CounPROGRAMcil ncil EXPENDITURES Grant Request Award Salary and Wages 10,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Aloha Independent Living Hawaii Transportation 10 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name:Transportation Agency Director: Roxanne Bolden Phone No.:(808 )497 —7996 Contact Person: Roxanne Bolden Phone No.:(808 )497 —7996 Mailing Address: Address: P.O. Box 283 Address: City,ST,Zip Pearl City, Hawaii 96782 • Facility Address: Address: 1055 Kino'ole Street Suite 202 Address: City, ST,Zip Hilo, Hawaii 96720 Email Address: rubolden@alohailhawaii.org Fax No.: (800 ) 385 —2454 Accountant/CPA: Darrel Lim Phone No.:(808 ) 522 —8833 Firm (if applicable): Darrel Um and Company Inc Mailing Address: Address: 81 South Hotel Street Unit 300 city,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FI!VANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 M�- Geographical Areas To Be Served: (One or more can be checked) El Puna Hamakua I I North Kona n South Hilo I I North Kohala ❑ South Kona North Hilo n South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes I Culture and the arts rill Aged n Victims of Health or Social Crises ISI Needs of the poor n Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Transportation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 0 0 0 2. Agency Mission Statement: To provide independent living programs and services to persons with disabilities living in Hawaii. 3. Program Description: To provide accessible curb to curb transporation to our consumers with disabilities that live in areas that public transporation is currently not able to do so. 4.Total Budget & Position Count: Total Program Budget: $39,000 Total Program Position Count: 1 Total Agency Budget: $77,600 Total Agency Position Count: 15 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Ha'wai`i Nonprofit Grant Application FY2021-22 Agency Name: Aloha Independent Living Hawaii Program Name: Transportation CE&^'+.rrs?."mmm.-el„ n.•'azs^.'P�w..,,. t m,u.-..;..•..-, _...v xww-.amm,n.R 1S@wuu. m^;T'1'"1.flL'^ . ;r...n...mm wc�.^T^m^..2"n. ^ :: C': .D*r.^ .. ^rta , 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Title VII Part C Independent Living Services Funded by DHS under ACL $438,216 Title VII Part t3 Independent Living Services Funded by OHS under DVR $290,939 County of Hawaii _ $5,000 Foundation Grants $5,133 Individual Contributions $10,000 TOTAL: $749,288 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: AILH is currently using CARES ACT funds to provide this program. However,funding will stop by Sept.2021. AILH is currently applying for other grants to help support both operational and programmatic costs. In addition,we are continually working on developing new, creative resource opportunities, including: -Federally funded grants and contracts -State funding grants and contracts -local government grants and contracts -fundraising events 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.To provide curb to curb accessible transportation in Hilo to consumers with disabilities to the following establishments: -doctor appointments at clinics or hospital -pharmacies to pick up medications -grocery shopping without time limitations -banks -post office -clinical laboratories for blood work -local businesses or organizations as needed by the consumer -laundromat Our van driver provides additional suppport by accompanying our consumers who are blind or visually impaired inside buildings to ensure that they arrive at the correct location. This is something that was needed during this time of COVID as previous supports were no longer available for consumers with significant disbilities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name:Transportation 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Transportation to Doctors or clinics 5 Transportation to Pharmacy 5 Transportation for Grocery shopping 20 Tranportation for banking 5 Transportation to post office or other businesses 5 Transportation to Clinical Laboratories 2 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 15,409 32,000 10,000 Professional Fees 715 1500 Operations Supplies 759 1700 Equipment Other: gas/ registration/ repairs i� 1636 3800 Other: Other: Other: Other: TOTAL 18,519 39,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name:Transportation 10. ORGANIZATION C•NFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 10 Member or members of the Council [l Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: III If no conflicts exist, check here. 21 4/1-0----- 1 /25/2021 S'- nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 202.1-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application 7-W2021-22 Agency Name:Aloha Independent Living Hawaii Program Name:Transportation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation ation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature ature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name:Transportation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. b 1 /25/2021 Sip�ature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of I Iawai`i Nonprofit Grant Application FY2021-22 Agency Name:Aloha Independent Living Hawaii Program Name:Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Transportation to Doctors or clinics 5 Transportation to Pharmacy 5 Transportation for Grocery shopping 20 Tranportation for banking 5 Transportation to post office or other businesses 5 Transportation to Clinical Laboratories 2 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 ALS '®hang of Hawaii Excellence in ALS Care Initiative - Equipment Loan Program and Direct Assistance Grants 12 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name:Excellence in ALS Care Initiative - Equipment Loan Program and Direct A: Agency Director: Natalie W. Fonda, President & Treasurer Phone No.:(808 ) 258 —9388 Contact Person: Natalie W. Fonda Phone No.:(808)258 —9388 Mailing Address: Address: 800 Bethel, Suite 405 Address: City,ST,Zip Honolulu, HI 96813 Facility Address: Address: N/A Address: City,ST,Zip Email Address: nataliejones@alsohana.org Fax No.: (808 ) 599 —3736 Accountant/CPA: Ronelle Matsunami, CPA Phone No.:(808) 837 —2505 Firm (if applicable): The CPA Collective Mailing Address: Address: 711 Kapiolani Blvd, Suite 1430 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $2100.0 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑■ Hamakua rj North Kona n South Hilo 0 North Kohala 0 South Kona O North Hilo 0 South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts Q Aged 0 Victims of Health or Social Crises O Needs of the poor D Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct A: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6175 $7125 2.Agency Mission Statement: The mission of ALS Ohana of Hawaii is to enhance the quality of life for those individuals in Hawaii who are affected by ALS by providing compassionate,practical support.ALS is a fatal, neurodegenerative disease that attacks nerve cells in the brain and spinal cord.As the disease progresses, people with ALS lose the ability to speak, move,swallow—and, eventually,the ability to breathe.All five senses function normally and most people with ALS remain completely aware as their bodies degenerate and they become increasingly immobile and dependent.ALS strikes women and men of all ages and backgrounds. 1 in 400 adults over 40 are at risk and research shows that veterans are twice as likely to be diagnosed with ALS than civilians.Annual costs for medical treatment, home care, and necessary equipment(for speech, mobility, and transportation, etc.)typically exceed$200,000, many of these costs are not covered by third party payers.ALS does not just affect the person diagnosed, it affects family members of all ages, caregivers and care partners, and entire communities. ALS Ohana of Hawaii is a community-based,volunteer-led organization and we partner with program providers to fulfill our mission, including The ALS Association Golden West Chapter.The mission of the Golden West Chapter is to discover treatments and a cure for ALS, and to serve, advocate for,and empower people affected by ALS to live their lives to the fullest. 3. Program Description: ALS Ohana of Hawaii seeks to renew funds for the Excellence in ALS Care Initiative in support of a crucial Equipment Loan Program as well as secure new funding for essential direct assistance grants. Most people diagnosed with ALS require durable medical equipment(power wheelchairs,shower chairs, ramps,etc.) and adaptive communication technology(speech generating devices, adaptive switches,etc.)to live safely and sustain quality of life as the disease progresses and individuals lose the ability to move,speak,swallow and breathe. As these functions diminish, in many households,the ability to maintain income diminishes as well, as the person with ALS and family members become limited in their ability to work due to physical challenges and assuming new caregiving responsibilities.The decreases in household income occur as expenses related to ALS care increases. Today those financial hardships are exacerbated by the economic impact of COVID-19. Direct assistance grants ensure that individuals without the financial resources or insurance coverage to address expenses related to ALS care including home modifications,respite care and counseling to name a few. Direct assistance grants also provide the means for individuals who rely on electricity and batteries to power life sustaining essential equipment to pay utility bills or to purchase small generators which are necessary in the event of a power outage or natural disaster. Golden West Chapter staff are uniquely positioned to assess and address these crucial needs of the ALS community. 4.Total Budget & Position Count: Total Program Budget: 0 Total Program Position Count: 0 Total Agency Budget: $15,806.53 Total Agency Position Count: o EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct A. 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii GIA $10,000 TOTAL: $10,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In addition to regular annual fundraising efforts,ALS Ohana of Hawaii will partner with the Golden West Chapter to increase revenue to support this program. Potential sources of increased revenue includes:government grants; virtual/online community outreach events and activities;philanthropic gifts from individuals,families and foundations; estate gifts;and local corporate support.All of these opportunities will be explored throughout the year for viability and implementation if appropriate. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objectives related to this request are to: -Address daily living and quality of life issues related to health,safety,communication and mobility for people living with ALS -Facilitate functional communication for people with ALS -Maximize access to skilled support to train people with ALS and their loved ones to use adaptive equipment adeptly EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct AE 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of pieces of equipment loaned 20 Number of equipment loan consultations 20 Number of beneficiaries 10 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $3,500 $3,500 Professional Fees Operations $2,500 $2,500 Supplies Equipment $10,000 $10,000 Other: Direct Assistance Grants $5,000 $5,000 Other: Other: Other: Other: TOTAL $21,000 $21,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct As 1.0. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed: One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that.apply): 0 Member or members of the Council ® Staff appointed by a member of the Council O The Mayor ® The Managing Director The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. d../kAaA. I I.7e Tvfevis&A KCS / as I a o a l Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct As 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct As 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. \akt.L___QA I asIa0z-1 Signature of Authorized Person Date President and Treasurer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Equipment Loan Program and Direct As 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 AILS '®hang of Hawaii Excellence in ALS Care Initiative- Professional Care Management 13 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name:Excellence in ALS Care Initiative - Professional Care Management and SL Agency Director: Natalie W. Fonda, President & Treasurer Phone No.:(808 ) 258 -9388 Contact Person: Natalie W. Fonda Phone No.:(808 )258 —9388 Mailing Address: Address: 800 Bethel, Suite 405 Address: City,sT,zip Honolulu, HI 96813 Facility Address: Address: N/A Address: City,ST,Zip Email Address: nataliejones@alsohana.org Fax No.: (808 ) 599 —3736 Accountant/CPA: Ronelle Matsunami, CPA Phone No.:(808 837 -2505 Firm (if applicable): The CPA Collective Mailing Address: Address: 711 Kapiolani Blvd Suite 1430 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $46,000 $Y q Geographical Areas To Be Served: (One or more can be checked) O Puna ❑■ Hamakua Q North Kona n South Hilo 0 North Kohala El South Kona O North Hilo South Kohala �■� Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts Q Aged 0 Victims of Health or Social Crises • Needs of the poor Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Professional Care Management and SL 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $5550 $13,750 2. Agency Mission Statement: The mission of ALS Ohana of Hawaii is to enhance the quality of life for those individuals in Hawaii who are affected by ALS by providing compassionate, practical support.ALS is a fatal,neurodegenerative disease that attacks nerve cells in the brain and spinal cord.As the disease progresses, people with ALS lose the ability to speak, move,swallow—and, eventually,the ability to breathe.All five senses function normally and most people with ALS remain completely aware as their bodies degenerate and they become increasingly immobile and dependent.ALS strikes women and men of all ages and backgrounds. 1 in 400 adults over 40 are at risk and research shows that veterans are twice as likely to be diagnosed with ALS than civilians.Annual costs for medical treatment, home care, and necessary equipment(for speech, mobility, and transportation, etc.)typically exceed$200,000, many of these costs are not covered by third party payers.ALS does not just affect the person diagnosed, it affects family members of all ages,caregivers and care partners, and entire communities. ALS Ohana of Hawaii is a community-based,volunteer-led organization and we partner with program providers to fulfill our mission, including The ALS Association Golden West Chapter.The mission of the Golden West Chapter is to discover treatments and a cure for ALS, and to serve, advocate for, and empower people affected by ALS to live their lives to the fullest. 3. Program Description: ALS Ohana of Hawaii seeks to renew funding to support professional care management and support services related to the Excellence in ALS Care Initiative,a program designed to: 1)ensure that no one is alone with ALS;2) provide people with ALS and their loved ones with access to the best possible proactive care and support;and 3)engage the ALS community in the search for effective treatments and cures. Past funding from the County of Hawaii in support of the Excellence in ALS Care Initiative has increased access to professional care management and services for people with ALS living in the County of Hawai'i.ALS Ohana of Hawaii will partner with the Golden West Chapter to provide comprehensive professional Care Management and support services to help people with ALS,their family members,and caregivers,to address challenges of daily living as the disease progresses, and to find solutions for the loss of the ability to move,swallow,speak and eventually,to breathe.The model of care offered is proven to help people live longer and better with ALS, even when using telehealth strategies that are now employed to keep communities safe from COVID-19. In fact,during the current pandemic,telehealth approaches have helped to improve access to services and expand program offerings to the ALS community.Care Managers connect individuals and families to essential information, community resources and events,educational opportunities, other people with ALS and their families, and coordinate access to and training for durable for medical equipment(power wheelchairs, etc.) and technology(augmentative communication devices,speech generating devices,adaptive switches, etc.) necessary to make living with ALS easier. Care Managers also collaborate with medical specialists and convene multidisciplinary ALS clinical teams to provide specialized,expert care related to neurology,pulmonology,speech language pathology,physical and occupational therapy, nutrition and more, all of these disciplines are essential to the proactive treatment of ALS. 4. Total Budget & Position Count: Total Program Budget: 0 Total Program Position Count: 0 Total Agency Budget: $15,806.53 Total Agency Position Count: o EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 • Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Professional Care Management and Su 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii GIA $16,000 TOTAL: $16,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In addition to regular annual fundraising efforts,ALS Ohana of Hawaii will partner with the Golden West Chapter to increase revenue to support this program. Potential sources of increased revenue includes:government grants; virtual/online community outreach events and activities;philanthropic gifts from individuals,families and foundations; estate gifts;and local corporate support.All of these opportunities will be explored throughout the year for viability and implementation if appropriate. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objectives related to this request are to: -Maximize access to care support, expert multidisciplinary medical care and community resources to help people live longer and better with ALS - Increase the number of people with ALS served in the County of Hawaii - Reach people living with ALS in the earliest stages of the disease EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care.Initiative - Professional Care Management and Su • 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of people with ALS served 15 Number of caregivers served 20 Number of Support Groups Offered for Hawaii residents 45 Number of County of Hawaii Program attendees(virtual multidisciplinary clinics,online support groups,webinars,virtual community events) 45 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $35,000 $35,000 Professional Fees $5,000 $5,000 Operations $10,000 Supplies Equipment Other: travel (when possible including transportation, lodgi $6,000 $6,000 Other: Other: Other: Other: TOTAL $56,000 $46,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Professional Care Management and Su 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. r A Pt2osUDeLsr -crc k+1. t/ S!a--O -z. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Professional Care Management and Su 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Professional Care Management and Su 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. I Signature of Authorized Person Date President and Treasurer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative - Professional Care Management and Su 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM Applicant Council Proposed PERFORMANCE MEASURES Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 American National Red Cross,The Disaster Preparedness & Response in Hawaii County 15 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The American National Red Cross Program Name:Disaster Preparedness & Response in Hawaii County Agency Director: Diane Peters-Nguyen Phone No.:(808 ) 292 —7277 Contact Person: Minette Lew-McCabe Phone No.:(808 ) 348 —8593 Mailing Address: Address: 4155 Diamond Head Rd. Address: City,ST,zip Honolulu, HI 96816 Facility Address: Address: 55 Ululani St. Address: City,ST,zip Hilo, HI 96720 Email Address: minette.lew@redcross.rog Fax No.: (808 ) 735 —8626 Accountant/CPA: KPMG LLP Phone No.:(703) 286 —8000 Firm (if applicable): KPMG LLP Mailing Address: Address: 1676 International Dr. City,ST,zip McLean, VA 22012 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 Geographical Areas To Be Served: (One or more can be checked) O Puna ❑■ Hamakua North Kona g South Hilo ❑■ North Kohala ❑■ South Kona ❑■ North Hilo ❑� South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 1 e $6,675 $9,043 $24,750 2. Agency Mission Statement: The mission of the Red Cross is to prevent and alleviate human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors. In Hawaii,we have assisted our community during every major local disaster since 1917,when the Hawaii Red Cross was founded. Our organization fulfills its humanitarian mission and delivers help, hope, and healing by meeting the immediate emergency needs of disaster victims;sharing vital disaster preparedness information through community disaster education outreach; providing emergency communication between military service members and their families in times of crisis; sponsoring the Human Animal Bond Program at Tripler Army Medical Center;and teaching people how to save lives through standardized training programs. The American Red Cross is the nation's premier emergency response organization and is committed to helping people through the entire disaster cycle,which includes preparedness, response, and recovery. When devastating events occur, people in need turn to the American Red Cross for immediate relief, hope to overcome staggering losses,and support as they piece their lives back together. The Red Cross serves as a safety net for victims of everyday disasters who have nowhere else to turn. Following our principle of impartiality, all Red Cross disaster services are available free of charge. 3. Program Description: Disaster relief is a vital part of our mission. The American Red Cross is the only nonprofit organization that responds to disasters 24/7, 365 days a year;our services are essential and irreplaceable. The American Red Cross of Hawaii responds every four days to disasters here at home, and the immediate and compassionate services provided to those affected reduce the harsh physical and emotional distress that prevents people from meeting their own basic needs following a disaster. Disasters and emergencies happen quickly and often unexpectedly, leaving people scrambling to help or get help. The geographic remoteness of Hawaii makes community preparedness and resiliency imperative. Following a major disaster, our logistics bridge could become compromised and critical resupply of items such as food, medical supplies and fuel could be delayed for weeks. Educating the public about being prepared will enable entire communities to recover from disasters of all sizes. As studies demonstrate, being prepared-having the resources and plans in place to withstand disaster-is a key component to mitigating disaster risk and is essential to a community's ability to recover. Prepared communities fare better following disasters: more lives are saved, less money is required for recovery,and a community stabilizes more quickly when it is resilient(Disaster Resilience:A National Imperative, National Research Council,Washington D.C.: q Y P 9 National Academies Press, 2012). Every$1 invested in pre-disaster preparedness and mitigation activities saves$6 in post-disaster response and recovery expenses(The Natural Hazard Mitigation Saves:2017 Interim Report). 4. Total Budget & Position Count: Total Program Budget: $237,352 Total Program Position Count: 1 Total Agency Budget: $4,770,680 Total Agency Position Count: 23 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 b County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $50,000 Hawaii Island United Way $7,000 West Hawaii Fund of the Hawaii Community Foundation $5,000 Other contributions(individuals,corporations) $140,000 Subsidy by American Red Cross to meet deficit $35,352 TOTAL: $237,352 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Red Cross is not a government agency and does not receive federal funding for disaster operations.We rely on the generosity and aloha spirit of Hawaii's people to deliver crucial services to the public free of charge and are grateful for the long-term commitment of our community. Starting with our local board,we continually work to expand our funding relationships and do everything to obtain support from individuals, businesses,and foundations to cover a local revenue goal exceeding$3 million. The American Red Cross of Hawaii,following non-profit best practices, aims for 100% participation in the Board of Directors'giving campaign. This effort is led by our Chair who also heads our Board Philanthropy Committee. 7. Program Objectives Using County Nonprofit Grant Program Funds: The following goals and objectives have been defined for the Disaster Preparedness&Response Program: Disaster Response-Meet the immediate emergency needs of disaster survivors (food,shelter and crisis counseling). Disaster Preparedness-Conduct free educational presentations to help communities be better prepared for crises.This includes educating children about disaster preparedness via the Red Cross Pillowcase Project(grades 3-5)and Prepare with Pedro(grades K-2).This also includes older individuals via Homes Made Safer, Ready Rating, and Be Red Cross Ready presentations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross g Y Program Name: Disaster Preparedness & Response in Hawaii County 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of disaster responses 12 Number of individuals assisted after a disaster 24 Number of individuals reached through Homes Made Safer,Ready Rating,and Be Red Cross Ready 100 Number of children reached with preparedness information 200 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $158,460 $50,000 Professional Fees $6,421 Operations Supplies $4,728 Equipment $5,013 Other: Disaster relief assistance (unpredictble) $25,842 Other: Travel, postage, gas $2,094 Other: Buildings & Occupancy $10,624 Other: Contractual Services $11,910 Other: Depreciation $12,260 TOTAL $237,352 $50,000 *If applicable PLEASE NOTE: We have calculated our budget differently this year using a budget generated by our National Office, as we feel those submitted previously did not reflect the true program operating costs. The American National Red Cross uses a budget allocation model to draft Chapter Budgets. Chapter Budgets include "locally incurred costs"and "centrally incurred costs." In a Chapter Budget, local direct costs, local indirect costs, and centrally incurred costs are allocated based on criteria specific to the expense/revenue type. The Disaster Response & Preparedness Program Budget formula relies mainly on population criteria for the allocation of centrally incurred costs. Other factors integrated into the formula include factors such as number of families assisted, training revenue, full-time employees, and volunteers. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■❑ If no conflicts exist, check here. 1 /14/2021 Signature of Authorized Person (specify title) Division Vice President Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Michael Jordan 1 /14/2021 Signature of Authorized Person Date Division Vice President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 Countyof Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of disaster responses 12 Number of individuals assisted after a disaster 24 Number of individuals reached through Homes Made Safer,Ready Rating,and Be Red Cross Ready 100 Number of children reached with preparedness information 200 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $50,000 Professional Fees Operations Supplies Equipment Other: Disaster relief assistance (u Other: Travel, postage, gas Other: Buildings & Occupancy Other: Contractual Services Other: Depreciation TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 The American National Red Cross 41) Disaster Preparedness& Response in Hawaii County Additional Narrative for#3—Program Description During FY19 (7/1/19—6/30/20),the Hawaii Red Cross delivered help, hope and healing to the people of Hawaii County: we responded to 23 disasters and assisted 62 survivors on the Big Island. Twenty smoke alarms were installed prior to COVID-19 social distancing restrictions suspending the program. We maintained a base of 274 disaster volunteers, of which 50 have taken specialized COVID-19 training allowing them to work in Hurricane Evacuation Shelters. Our records indicate that in FY20, at least 48% of the clients the American Red Cross of Hawaii served in the County of Hawaii during disaster response were also living in poverty. An Aloha United Way commissioned report entitled ALICE: A Study of Financial Hardship in Hawaii confirmed the stark reality there are many people in Hawaii who struggle every day to make ends meet. ALICE is an acronym for Asset Limited, Income Constrained, Employed.The ALICE population is comprised of people who have a job or multiple jobs yet can't afford the basic necessities to remain stable and self-sufficient. According to the 2019-20 report, approximately 48%of Hawaii County households were estimated ALICE and below prior to the COVID-19 pandemic. Disasters directly threaten the homes of ALICE families since more affordable housing is often located in vulnerable areas (ALICE: A Study of Financial Hardship in Hawaii, 2020). All it takes is just one crisis to put this population at an even greater risk of long-term problems. Red Cross disaster relief provides a safety net for those who need it in the aftermath of a disaster. Following our principle of impartiality, all Red Cross disaster services are available free of charge to anyone in the state of Hawaii who falls victim to natural and man-made disasters. DISASTER RESPONSE The Red Cross is able to respond at a moment's notice because of our year-round readiness efforts. Disaster relief services help bridge the gap between disaster-caused hardship and hope to help affected families and communities recover. The Red Cross performs government-like functions as we assist the county, state and federal government in their responsibility to provide for the welfare of those who reside in their jurisdictions. We provide a public purpose in assisting the people of Hawaii whenever a disaster strikes by supporting the State of Hawaii in its emergency management role. The American Red Cross of Hawaii is written into the Hawaii State Emergency Management Agency plans for notification, and is heavily relied upon to provide, manage, and operate shelters and conduct mass feedings during disasters, as well as complete damage assessment following disasters. The American Red Cross of Hawaii is designated as the lead organization by all counties to plan and execute disaster sheltering operations. A prime example of this are the following recent disaster relief responses: Hawaii Island(North Kohala)Multiple Family Fire—March 2020 On March 17, a fire broke out in a garage of a small apartment building in North Kohala. Four units were destroyed, and one person was taken to the hospital. With new COVID-19 guidance, our Red Cross dispatcher contacted the client to verify that they were well enough to meet with 1 The American National Red Cross +i Disaster Preparedness & Response in Hawaii County Additional Narrative for#3—Program Description our volunteers and that likewise our volunteers were comfortable with visiting the client. The North Hawaii Disaster Action team met with the client and provided financial assistance and lodging following social distancing guidelines. Nurses followed up with two clients to assist with replacement of glasses and medication. Hawaii Island(Pahala)Fatal Fire—June 2020 On June 13, a fire in a Pahala single-family home took the life of an elderly woman. The son tried to run upstairs to rescue his mother but was unable to reach her in time and she died in the fire.The Red Cross provided crisis counseling for the family and financial assistance to assist with memorial costs. COVID-19 Missions On Hawaii Island, volunteers helped Project Vision Hawaii with delivering meals to students with disabilities. DISASTER PREPAREDNESS The unexpected and unprecedented impact of COVID-19 continues to affect delivery of our services. It has become apparent in the current environment that the need to be able to deliver services virtually is key. We have successfully transitioned our preparedness presentations to an online format. Home Fire Campaign The most common disaster is a house fire. As part of the Home Fire Campaign, we install smoke alarms, replace smoke alarm batteries, and provide of fire safety education. However, the smoke alarm installation element of this program has been on hold due to COVID-19 social- distancing restrictions. In the meantime, we are developing new approaches for smoke alarm installation, including potential partnerships with fire departments. We are also considering virtual methods of developing evacuation plans and monitoring smoke alarm installation. We continue to offer "Homes Made Safer" virtually, which was the educational portion of the home visit. This includes helping families to develop a plan to evacuate their home within two minutes and to draw up a plan with meeting points, in addition to educating households about other hazards that they may face in Hawaii. Pillowcase Project& Prepare with Pedro When disasters strike, children are an especially vulnerable part of the affected population. The Pillowcase Project teaches keiki in grades three to five about disaster preparedness, coping skills, and the science behind disasters. Prepare with Pedro will provide an introduction for students in grades K-2 to the concept of emergency preparedness in a fun and educational way - using storytelling and hands-on activities, students will build muscle memory and basic coping skills. These programs empower youth to prepare before a disaster occurs, enhance learning, and promote safety. Through the Pillowcase Project and Prepare with Pedro, the Red Cross reaches children, and by extension their families, with vital disaster preparedness information. 2 The American National Red Cross - Disaster Preparedness & Response in Hawaii County Additional Narrative for#3—Program Description Red Cross disaster relief provides a safety net for those who need it in the aftermath of a disaster, and our preparedness initiatives endeavor to prevent disasters, like home fires, from happening. Thank you for your consideration of our request. With the continued support of the County, our dedicated volunteers will respond to disaster faster, be better equipped, and provide enhanced services to those in need. Be Red Cross Ready& Ready Rating Be Red Cross Ready is a national, standardized, preparedness education curriculum for adults. The program is designed to help people understand, prepare for and respond appropriately to disasters. The curriculum has the option to mix and match emergency preparedness modules on relevant local hazards. These modules include: Preparedness Essentials, Home Fires, Hurricanes, Floods,Tsunamis, Wildfires, Volcanoes, and COVID-19. Ready Rating is a free and easy, web-based membership program that allows organizations to use one of two proprietary assessments to measure their current state of preparedness. Then based on their own score,the program provides a Next Steps Report which helps them develop a complete Business Continuity Program. 3 Arc of Kona Health and Wellness for All Abilities 17 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Arc of Kona Program Name:Health and Wellness for All Abilities Agency Director: Michele Ku, President/CEO Phone No.:(808 ) 323 —2626 Contact Person: Michele Ku, President/CEO Phone No.:(808 ) 323 -2626 Mailing Address: Address: PO Box 127 Address: City,ST,Zip Kealakekua, HI 96750 Facility Address: Address: 81-1065 Konawaena School Road Address: City,ST,Zip Kealakekua, HI 96750 Email Address: michele@arcofkona.org Fax No.: (808 ) 323 —9444 Accountant/CPA: Ann N. Fukuhara, CPA, MBA Phone No.:(808) 961 —5532 Firm (if applicable): Ann N. Fukuhara, An Accountancy Corp. Mailing Address: Address: PO Box 6691 City,sr,Zip Hilo, HI 96720 YOU ARE.RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑® Puna ❑® Hamakua North Kona North Kohala n South Hilo ❑ South Kona 0 North Hilo n South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) Eu Educational concerns I I Youth LI Victims of Crimes n Culture and the arts n Aged Victims of Health or Social Crises ❑ Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment amnesx EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 9,300.00 10,548.00 5,850.00 2. Agency Mission Statement: The Arc of Kona is a private nonprofit organization for persons with disabilities,their advocates,and families.We believe that people with disabilities are as individual in their needs, abilities,and gifts as any other cross section of society.We believe that all people of all abilities have the same fundamental human rights which includes participating and being included in our communities.As a result,our mission is to help persons with disabilities achieve the fullest possible independence, participation,and inclusion in our society according to their wishes. 3. Program Description: Health and Wellness for All Abilities is a virtual health and fitness program that embraces individuals of all abilities and is designed to meet each individual Participant's needs and preferences for increasing their health and fitness and living a happy and healthy life.The program provides increased Participant virtual access to their peers throughout the island and other communities and individuals across the nation in a safe way.This also presents an opportunity for our Participant's to socialize and build relationships with people in different states that they would not have been able to connect with in the past.This program is designed to be accessible 365 days per year at any time of day to individuals with Intellectual and Developmental disabilities and their Direct Support Staff and natural caregivers.We recognize that exercise and fitness is not only an essential part of living a happy and healthy life, it is also a human right.The people we serve are extremely vulnerable and at a higher risk of experiencing severe life threatening symptoms if they contract Covid-19 and/or any other illness or disease.As an essential business providing day-to-day critical services to our Participants,we realized we needed to create a way to continue to promote healthy living, but in a safe and socially distanced manner.As a result,we have partnered with an organization called Spirit Club to make this program a reality.This program offers various virtual fitness classes that can be modified for each individual to be able to participate in to achieve a fulfilling workout experience. Each exercise will directly improve natural movements, increase balance,flexibility,strength, coordination, endurance, agility, and ability to prevent injuries.Some of the classes include yoga,cardio fitness,zumba, boxing, meditation, balance fitness,strength fitness, and healthy cooking.These virtual fitness classes are unique because they are inclusive, supportive, and consist of multiple trainers demonstrating different versions of each exercise in various modified forms, including seated, standing, and progressed. 4.Total Budget & Position Count: Total Program Budget: $292,600 Total Program Position Count: 21 Total Agency Budget: $3,887,713 Total Agency Position Count: 103 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Department of Health,Medicaid Waiver Home and Community Based Services $269,600 Hawaii Island United Way $15,000 Agency Fundraisers $5,000 Donations $3,000 County of Hawaii $22,400 TOTAL: $315,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Arc of Kona is proactive and strategically seeks funding through a variety of resources to support our agency and program including: 1.Grant Funding:Actively seeking both government and non-government grant funding opportunities to supplement the program budget. 2. Donor Cultivation: Maintain current donors and cultivate new donors to increase annual donations. 3. Partnerships: Partnerships with other organizations include but are not limited to The Arc of the United States,West Hawaii Rotary Clubs, Lions Clubs, Ko Education Center, SPIRIT Club, and UH Manoa Centers for Disability Studies for additional funding support and/or in-kind donations and services.We are also partnered with various employers island-wide. 4. Fundraising: Exploring various fundraising opportunities that are acceptable and compliant with state requirements during a global pandemic. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Enhance the lives and minimize the risk of the people we support during a global pandemic, 2. Create and provide a safe, healthy, active, and supportive learning environment, 3. Increase level of independence and a healthy lifestyle for individuals with Intellectual and/or Developmental Disabilities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are yourneasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Maximize number of Participants served island-wide Serve a minimum of 70 program Participants island-wide Ensure the safety of Participant's during the program service delivery Zero adverse events Increase Participant level of independence on applicable health and wellness goals Average 25%increase overall Increase Participant attendance through virtual live or previously recorded fitness classes Participant attendance at 75% Gauge Participant/family program satisfaction via satisfaction surveys Minimum 90%satisfaction rate Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 304,800 21,673 Professional Fees 3,000 214 Operations 7,200 513 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $315,000 $22,400 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ■ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • n If no conflicts exist, check here. -.,..///// 4.7 "kph/el d '"?.) ealF7/AP/ Signature of Aho'zed_Person (speciy e) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135-2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant; contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.Rov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover thesef unds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ate ► gi GV/1/6ff ® / Signature of Aut .rized Perso Date President/CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021- 2022 Page 7 of 8 . . County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arc of Kona Program Name: Health and Wellness for All Abilities 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Maximize number of Participant's served island-wide Serve a minimum of 70 PzrUcipanty island-vdd Ensure the safety of Participant's during the program service delivery Zero adverse events Increase Participant level of independence on applicable health and wellness goals Average25%increaseoverall Increase Participant attendance through virtual live or previously recorded fitness classes Participant attendance at 75% Guage Participant/family program satisfaction via satisfaction surveys Minimum 90%satisfaction rate TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 21,673 Professional Fees 214 Operations 513 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $22,400 Additional C.unci) directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Arts & Sciences Center ASC Community Education Services • 18 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Arts & Sciences Center Program Name:ASC Community Education Services Agency Director: Gail Clarke Phone No.:(808 ) 938 —2933 Contact Person: same + alt- McLean Eames - secretary Phone No.:(808 ) 965 —3730 Mailing Address: Address: PO Box 2091 Address: City,ST,zip Pahoa, HI 96778 Facility Address: Address: 15-1397 Homestead Road (No USPS mail delivery) Address: City,ST,zip Pahoa, HI 96778 Email Address: ascpuna@gmail.com Fax No.: (808 ) 965 —3733 Accountant/CPA: Rozanne Connell Phone No.:(808) 930 —6850 Firm (if applicable): Carbonaro and Associates Mailing Address: Address: PO Box 4372 136 Kinoole St city,sr,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna ❑ Hamakua ❑ North Kona ❑South Hilo [' North Kohala ❑South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'i Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ■❑Youth ❑Victims of Crimes ❑■ Culture and the arts Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $9750 $14,550 $23,750 2.Agency Mission Statement: ASC formed as a 501c3 in 2003,to provide outstanding support and infrastructure for community-based learning rooted in Puna.ASC envisions learning and sharing opportunities to empower participants to thrive, cooperate, innovate and serve. ASC works to provide(1)access to education, (2)stewardship of diversity and cultural infusion, (3)stewardship of our environments, and (4)partnerships for positive economic impacts. ASC has developed a Master Plan to support our strategic plan, exploring shared-workspace models that would allow students(K-12 and community), interns, mentors and entrepreneurs to work and learn together. Shared workspaces including an accessible kitchen to process value-added food,and Makery style shops and studios are needed and planned. Staff is needed to coordinate offerings.ASC has developed proposals for EDA Recovery and USDA Rural Development fund applications as well as private funding for Design, Engineering and Construction. 3. Program Description: Community Learning Festivals, launched in 2016. Festivals scheduled after March 2020,launched on virtual platforms supported by an updated website. Over 700 families are personally invited with a HAASPCS schoolwide message. Email, coconut wireless,fb and instagram are used to reach our wider community. Classes, Meet-Ups and Workshops are offered by ASC. Donations are accepted at all activities.Virtual options are currently offered, in person activities will resume as conditions allow.Weekly HI Language Classes and monthly Culture/Hawaiian perspective workshops began in Feb.2020.Yoga and TaiChi classes are offered in an open air pavilion with a Pacific Quest support,as a continuing wellness strategy. Entrepreneur Meet-ups are co-hosted with local business support and the SBDC and HIPlan.The Hawaii Island School Garden Network(HISGN)holds workshops,the island-wide Spelling Bee was hosted for the 4th year, and community groups(Diabetes support, Sewing)booked pre-pandemic, hope to continue. Community groups apply for use of facilities and fees are on a sliding scale. Supplementary activities focused on STEAM learning serve youth in East Hawaii, including HAASPCS with 725 grade k-12 students, and their ohana,mentors and students.STEAM=Science,Technology, Engineering,Art/Agriculture and Math is a broad approach facilitated by community mentors. Focus is on communication and awareness of people, places,global scientific and cultural, place-based knowledge,emerging challenges, and solution finding that increase quality of life, resilience and thriving together. 4.Total Budget & Position Count: Total Program Budget: 111,000 Total Program Position Count: 1.8 FTE Total Agency Budget: 227,270 Total Agency Position Count: 1.925 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate ASC General Funds(rent,fees,contributions) $1,000 County of Hawaii Grant $105,000 Other grants-Pacific Quest-YogalTaiChi TBD(-5,000) TOTAL: 111,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Pandemic conditions severely limit most program efforts and cash flow for program fees.ASC is stretching funding to allow as much access as possible,virtually and by gathering as conditions allow,following CDC and State guidelines for public safety. -Establish fair fees and advertise for the use of facilities including partnerships with agencies and groups such as : Hawaii Community College(HCC Running Start and other opportunities),food safety courses, HCEOC(HECO programs for low-income residents), HAASPCS Learning Garden,Small Business Development Center(SBDC),Aloha Hui o Puna Makai w Hawaiian Language classes, Friends of the Pahoa Skate Park, Pacific Quest, Paradise Ponies wood carvers, Korean Natural Farmers Hawaii and the Hawaii Island All Nations Pow-wow group. -Fees support(1)classes and workshops, (2)security and maintenance, (3)utilities and(4)ASC overhead that includes data tracking and analysis for reporting and planning. Community Learning Festivals include a small revenue stream from vendor booth spaces with free admission to the community. -ASC actively seeks grant funding to facilitate individuals and groups to learn,articulate,and implement entrepreneurial and service projects, including focuses on food security and resiliency. OUR PAHOA YOUTH NEED EXPANDED OPPORTUNITIES AFTERSCHOOL AND ASC IS POISED TO STEP IN AS FUNDING ALLOWS. 7. Program Objectives Using County Nonprofit Grant Program Funds: -Provide a safe and accessible place for community education,events, meetings and programs including two — four annual Community Learning Festivals and regular community classes(Hawaiian Language and Culture,Agriculture, sewing,Wellness and Yoga)and meetings(Entrepreneur Meet-up w guest speakers)serving up to 3000 residents, currently offered on virtual venue.This will be measured by number of opportunities offered and participants. -Support and coordinate a network of mentors (community and virtual), partners and multi-generational students who collaborate and produce together, in safe,afterschool and intersession programs,to strengthen our community and economy.This will be measured by number of opportunities offered and participants. Developing a model such as the Hilo Makery, in Pahoa,for access to shared tools and workspaces for STEAM projects is included in ASC's strategic Master Plan-see Project tab at www.ascpuna.org.The current STEAM space at HAASPCS is cramped in a shared classroom, severely limiting the work potential of students, let alone a wider community.Serving the wider community,to build resiliency by knowing each other and working together in improved facilities is an objective ASC is working to design, engineer and fund asap. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2O21-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Host 2-4 Community Learning Festivals—400-600/ea 800—2400 participants Host 20-50 community classes and meetings w sliding scale fees-track participation 200—500 participants Host and staff afterschool STEAM and student-mentor learning-track participation 80-300 participants Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 2113 40,000 40,000 Professional Fees in-kind 2,000 2,000 Operations 225 2,000 1,000 Supplies 401 1,000 1,000 Equipment Other: Festivals in Virtual/website format, gather as can 845 6,000 6,000 Other: Classes, workshops, community meetings 8102 20,000 15,000 Other: Community Network facilitator/ instructor in-kind 20,000 20,000 Other: Supplies & materials for STEAM activities 3819 20,000 20,000 Other: TOTAL 15,505 111,000 105,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organizationmay have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Gail Clarke POSITION: ASC Pres / EO May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): in Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor • The Managing Director • The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. f,r P ) 7 /—a7 20 41 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. KtE- - ;/-1 Signature of Authorized Person Date Title/Position of Authorized Person EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Host 2-4 Community Learning Festivals—400-600/ea 800-2400 Host 20-50 community classes and meetings w sliding scale fees-track participation 200-500 Host and staff afterschool STEAM and student-mentor learning-track participation 80-300 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 40,000 Professional Fees 2000 Operations 1000 Supplies 1000 Equipment 0 Other: Festivals in Virtual/website I 6000 Other: Classes, workshops, commi 20000 Other: Community Network facilital 20000 Other: Supplies & materials for STI 20000 Other: TOTAL 105,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Big Island Mediation, Inc. DBA West Ham/Mg Mediation Center Community Mediation 19 County of Hawai`i Nonprofit Grant Application FY2021-22 Island Mediation, Inc. DBA West Hawaii Mediation Center Agency Name:Big Program Name:Community Mediation Agency Director: Eric Paul Phone No.:(303 ) 335 —5525 Contact Person: Eric Paul Phone No.:(308 )365 —5444 Mailing Address: Address: 1'U I3UX /U20 Address: City, ST,Zip Kamuela, HI 96/43 Facility Address: Address: b5-1291 Kawainae KO. suite 1U4D Address: City,ST,Zip Kamuela, HI 96/43 Email Address: epaul@whmediation.org Fax No.: ( ) — Accountant/CPA: Angela Taft Phone No.:(808) 930 _685U Firm (if applicable): Carbonaro CPAs & Management Mailing Address: Address: 136 KIn001e st. City, ST,Zip H110, HI 96/20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) I Puna n Hamakua n North Kona South Hilo ®I North Kohala [®I South Kona North Hilo ® South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) I Educational concerns ® Youth I I Victims of Crimes ❑ Culture and the arts rm Aged I I Victims of Health or Social Crises Needs of the poor ( I Physical/Emotional Disabilities I Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Program Name: •1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,050 $8,033 $6,625 2. Agency Mission Statement: WHMC's mission is to provide dispute resolution and education services to empower individuals and build communities that view conflict resolution as a catalyst for positive change. 3. Program Description: West Hawaii Mediation Center is seeking funding to support our Community Mediation program.The Community Mediation and Outreach program has been in existence, in some form, since 1988. It remains our principal program and primary mode of fostering conflict resolution for West Hawaii neighbors.This program will remain a focus for WHMC into the lasting future. Our Community Mediation program works on a referral process, both from the courts and from community sources (whether individuals, workplaces, or community organizations). Mediation is a voluntary enterprise. We only mediate if both parties agree.This mechanism helps strengthen any agreements that might come from the session. Mediations are conducted by professionally trained volunteers, who work as neutral facilitators.They hold space for the parties to discuss what outcomes might work best for them. Mediators do not give legal advice or act as a type of arbitrator.This also strengthens any agreement that may result. We mediate custody, separation, divorce, landlord/tenant, civil rights, automobile, property disputes, condo agreements, and many more challenges that routinely occurs in West Hawaii. Mediation offers a low cost alternative to moving through the court system.According to the Mediation Centers of Hawaii "Economic Impact and Social Return on Investment Analysis,"for every$1 invested in mediation programs, they deliver $8.03 in immediate and long-term financial benefits for Hawaii residents. • 4.Total Budget & Position Count: Total Program Budget: $147,145 Total Program Position Count: 2.5 Total Agency Budget: $233,792 Total Agency Position Count: 3.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate urants - rrivate rounaatlon ana government 4ibU,uuu uontracts 4i3y,000 r►naiviaual uontnnutlons �u,uuu grogram rtevenue 4ii b,uuu tlzunaraising Cvents 4iL:i,uuu i — TOTAL: $147,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: West Hawaii Mediation Center has built five basic streams.for sustaining income:grants, contracts, program fees, individual donors, and fundraising events:This past year,we have continued to monitor and track individual donations and communicate with donors, established and held our first annual Peace Gala,and amended the process for our Events Committee.This year;we intend to organize our second annual Peace Gala, recruit two•new board members with an eye toward diversity and strategic relationships for fundraising,and-we have started to assess and amend our.2018-2020 Strategic Plan;in order to guide us for the next three years. • 7. Program Objectives Using County Nonprofit Grant Program Funds: West Hawaii Mediation Center's Community Mediation Program objectives are as follows: 1). Improve the quality of mediation services by increasing volunteer recruitment,training, and evaluation. -Conduct Outreach to recruit a diverse cohort of new volunteers. -Provide volunteer observational assessment and feedback -Sustain annual training calendar for new and existing volunteers; including zoom training for virtual mediations. 2). Provide high quality mediation services and education to the West Hawaii community. - Implement conflict resolution education workshops; including nonviolent communication and restorative justice; amended for both virtual and in-person modalities -Search and train new volunteers to implement post-mediation surveys for client feedback -Conduct mediations EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021- 2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Island Mediation, Inc. DBA West Hawaii Mediation Center Agency Name: Big Program Name: Community Mediation 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your i program?Describe,be specific.) lases iViecliatea ?5U inalviaual Lllents 5ervea 5UU -Active volunteer Meaiators �U vvor snopsi I rainings urrerea 1U __ Tient 5ausractlon tis"/(3 io or cuents unser VV2,uw bU"io Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 101,200 127,000 7000 Professional Fees 4,800 5000 Operations 21,000 24000 4000 Supplies 1900 2000 500 Equipment 1200 2500 500 Other: Training a-nd Outreach 5100 3000 1500 Other: Advertising and Promotion 6300 7200 Other: Administration/Support 5645 5500 500 Other: Other: TOTAL 147,145 176,200 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 1€lo ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): �] Member or members of the Council • [ Staff appointed by a member of the Council �] The Mayor Di The Managing Director I The Director of Finance Till The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: lioleka Inaba:WHMC Board Member since Oct.2019 has been elected as a Hawaii County Council Member.Tenn began in Dec.2020. Iron.Elizabeth Strance:WHMC Board Member since 2015.Board Term will end in June of 2021.Elizabeth Strance accepted a position as Corporation Counsel in the new administration for Mayor Mitch Roth El If no conflicts exist, check here. • 1/25/21 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021- 2022 Page 5 of 8 County of Hawai'i Nonprofit Grant Aplication FY2021-22 Agency Name: Big Island Mediation, Inc. DBA Wes Hawaii Mediation Center Program Name: Community Mediation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. i (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021- 2022 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/25/21 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai 6 i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 1 i TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages _ Professional Fees Operations Supplies Equipment • Other: Other: Other: I Other: [Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Big Island Miediatiou i, Inc. DBA West Hawaii Mediation Center Peer Mediation and Youth Conflict Resolution Education 20 County of Hawai`.i Nonprofit Grant Application FY2021-22 Agency Blame:Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Education Agency Director: Eric Paul Phone No.:(806 ) 385 _5525 Contact Person: Eric Paul Phone No.:(806 )365 —5444 Mailing Address: Address: NU 130X 1020 Address: City, ST,Zip Kamuela, HI 96/43 Facility Address: Address: 55-1291 Kawalnae Ha. Suite 104b Address: City,ST,Zip Kamuela, HI 96/43 Email Address: epaul@whmediation.org Fax No.: (803 ) 887 _0525 Accountant/CPA: Angela Taft Phone No.:(808) 930 _6350 Firm (if applicable): Carbonaro CPAs & Management Mailing Address: Address: 136 Klnoole St. City, ST,Zip HII0, HI 9612U YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 11 Puna !6.1 Hamakua n North Kona South Hilo SMI North Kohala n South Kona North Hilo South Kohala ri Ka`u Services or Activities To Be Provided: (One or more can be checked) FET Educational concerns ®I Youth I I Victims of Crimes Culture and the arts I I Aged I I Victims of Health or Social Crises n Needs of the poor Physical/Emotional Disabilities (— Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 - 2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Education 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 L $13,664 $10,050 $6,125 2. Agency Mission Statement: WHMC's mission is to provide dispute resolution and education services to empower individuals and build communities that view conflict resolution as a catalyst for positive change. 3. Program Description: Conflict resolution education and Peer Mediation program entails teaching youth about the nature of conflict and the typical ways people respond to it, recognizing and-managing difficult emotions, learning communication skills, and understanding and respecting differences. WHMC provides conflict resolution training to elementary, middle, and high school students to strengthen their communication skills and problem-solving skills. We promote peace through education that actively builds a youth culture and school climate that engages conflict in healthy and peaceful ways. Peer Mediation trainings and school-based programs provide a space for elementary school and middle school students to practice much needed communications skills, which are useful to help them begin to understand and resolve conflicts. We see results through the number of mediations that take place in these school settings, but also in terms of feedback we receive from school coordinators about the benefits to student development. This year, while students and teachers adjust to distance learning, WHMC continues to aid students in their social- emotional development through online interactive trainings. Now, in the midst of the pandemic,teachers need the aid of community organizations coming alongside our youth to teach healthy skills to manage stress, anxiety, miscommunication, and conflict. 4. Total Budget & Position Count: Total Program Budget: $39,800 Total Program Position Count: .5 Total Agency Budget: $233,792 Total Agency Position Count: 3.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Big Island Mediation, Inc. DBA West Hawaii Mediation Center Agency Name: Program Name: Peer Mediation and Youth Conflict Resolution Education 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate urants 4i30,uuu Inaiviauai Donations 6Wu runaralsers i51)0u TOTAL: $41,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: West Hawaii Mediation Center has built five basic streams for sustaining income:grants, contracts, program fees, individual donors, and fundraising events.This past year, we have continued to monitor and track individual donations and communicate with donors, established and held our first annual Peace Gala, and amended the process for our Events Committee. This year,we intend to organize our second annual Peace Gala, recruit two new board members with an eye toward diversity and strategic relationships for fundraising, and we have started to assess and amend our 2018-2020 Strategic Plan;in order to guide us for the next three years. 7. Program Objectives Using County Nonprofit Grant Program Funds: County of Hawaii funds will be utilized to support our Peer Mediation in public/private schools and youth education throughout West and North Hawaii. . Objective 1: Deliver Conflict Resdlution training and peer mediation to West Hawaii students to empower students with the skillset to overcome conflicts between peers. -Maintain existing relationships with Peer Mediation Coordinators in DOE schools. -Assess level of support necessary during the pandemic. -Review and Amend PM training materials for virtual trainings. Objective 2: Integrate conflict resolution education with youth orgnaizations focused on the arts. -Collaborate with Aloha Teen Theatre, Prince Dance Insitute, and Kona Dance and Performing Arts for youth focused conflict education - Build partnership with Yoga Impact to implement annual week long"Peace Camp"for middle schoolers. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Island Mediation, Inc. DBA West Hawaii Mediation Center Agency Name: Big Program Name: Peer Mediation and Youth Conflict Resolution Education B. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) iota) # or youtn eaucation participation 25U or mealauon conauctea ror elementary ana miaale scnoois 1 Uu _iF or community ana scnooi aasea partnerships 1 u -'io or stuaents who inaicate use or Urs eaucatlon outsiae or scnoouor t;5'io Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $20,800 127,000 9,000 Professional Fees 5000 Operations $11,000 24000 3,500 Supplies $500 2000 250 Equipment 2500 Other: Admin Support $6000 5500 2,250 Other: Advertising and Promotion 7200 Other: Training and Outreach 3000 Other: Other: TOTAL $39,800 176,200 $15,000 L *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Education nitammanneemszammelia loo. ORGANIZ* T1I:• N CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council O] The Mayor *1 The Managing Director ID The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 1-loleka I naba:WHMC Board Member since Oct.2019 has been elected as a Hawaii County Council Member.Term began in Dec.2020. Hon.Elizabeth Strance:WHMC Board Member since 2015.Board Term will end in June of 2021.Elizabeth Strance accepted a position as Corporation Counsel in the new administration for Mayor Mitch Roth ® If no conflicts exist, check here. 1/25/21 v Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Aplication FY2021 -22 Agency Name: Big Island Mediation, Inc. DBA Wes Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Education 11. Certification of Understanding (Page 1 of 2) (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021 -22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Education 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). 1 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. i (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/25/21 fes__ Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Education 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: L TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Big Island Resource Conservation & Development Council BIISC Invasive Species Early Detection and Rapid Response Program 22 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name:BIISC Invasive Species Early Detection and Rapid Response Program Agency Director: Larry Komata, President Phone No.:(808) 961-6425 Contact Person: Brandi Milare, Program Manager Phone No.:(808 )217 —7234 Mailing Address: Address: 200 Kanoelehua Ave. Address: PMB 285 city,sr,zip Hilo, HI 96720 Facility Address: Address: 433 Ulu Mau PI. Address: City,sr,Zip Hilo, HI 96720 Email Address: bircdl@gmail.com Fax No.: ( ) — Accountant/CPA: N/A Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 30,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona 0 North Hilo 0 South Kohala 0 Ka'U Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes 0 Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 did not apply $13,443 $23,300 2.Agency Mission Statement: The Mission of Big Island RC&D Council is to assist the people of the Big Island in achieving sustainable development while caring for,and appreciating their natural environment;to ensure broadened economic opportunities,enriched communities,and better lives.The Vision of Big Island RC&D Council is to conserve,enhance,and promote the economic,cultural,and natural environment of Hawai'i.Big Island RC&D is serving as fiscal sponsor for this proposal. The mission of the Big Island Invasive Species Committee(BIISC)is to address the highest risk invasive species threats to Hawaii Island's environment,economy,and way of life.We employ 18 staff and support interns each year,many of whom graduated from Hawaii Island high schools and from UH Hilo,and have gone on to steady employment with BIISC or other agencies. In everything we do,our guiding principle is public service. This project advances each of our missions by identifying and,through public education and pro-active control operations, halting the economic,environmental,and community impacts caused by incipient invasive species. 3. Program Description: In discussions about invasive species BIISC staff often hear sentiments such as,"Why didn't someone DO something about albizia before it got this bad?"or"If only we had eradicated gorse when we still had the chance."Well,80-100 years ago,decision makers might not have known how bad it could get...but when you know better,you do better!Today, BIISC's Early Detection and Rapid Response program works to predict,identify and eradicate the NEXT albizia,the NEXT gorse,the NEXT big bad scary thing,BEFORE it does"get that bad." We have developed clear,objective parameters to select invasive plant species for our eradication program--species that present the greatest risk to island resources,while also being in the early stages of invasion,when they are still feasible to control.These species include pests like the Barbados Gooseberry,whose thorns so resemble the crown of thorns sea urchin we have nick-named it"vana vine." It includes toxic Rubbervine,on the list of the World's Worst Weeds, and once planted throughout Kailua-Kona and Ka'u. It includes Photinia,a pretty little bush spread by birds that aggressively occupies all the best growing sites-blocking the regeneration of native keiki in Hakalau Forest National Wildlife Refuge,where our endangered Native Hawaiian forest birds are just hanging on.And we were thrilled to celebrate the news in 2020 that we had,after ten years of steady effort,eradicated fire-promoting Pampas Grass from the island. The requested County funds will be combined with$320,000 in state and federal funds in FY 21-22 to continue work towards eradication of eleven invasive plant species throughout the island. Funds will cover half the costs of a full time field associate,who will work full time in the field surveying for and controlling these invasive species. BIISC takes detailed data to track progress.All targets are on track to be eradicated within ten years.All except two new additions are down to the final stages,with fewer than two mature plants found per acre each year.Nevertheless,an average field associate removes more than 10,000 individual plants across 6,000 acres each year. 4.Total Budget&Position Count: Total Program Budget: $350,000 Total Program Position Count: 6(7FTE+3 at30%FTE support) (BIISC) Total Agency Budget: $1.8 Mil Total Agency Position Count: 18 (BIISC) BIRCDC Total Agency Budget: $38,865 BIRCDC Total Agency Position Count: 1 (Paid) and 11 volunteers EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Hawaii Invasive Species Council 250,000 US Fish and Wildlife Service 50,000 Hawaii Department of Agriculture 20,000 Hawaii County Non Profit Grant in Aid 30,000 TOTAL: $350,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BIISC relies primarily on steady funding from state and federal agencies with an established stake in controlling invasive species. These include the Hawaii Department of Agriculture, Department of Land and Natural Resources,the Hawaii Invasive Species Council,Hawaii Tourism Authority,the US Fish and Wildlife Service,and the US Forest Service.We also receive occasional funding from philanthropic funders. Building on our effectiveness and expertise at invasive species management,during the past five years BIISC has been awarded an average of nearly$2M in off-island funding to carry out our work across Hawaii Island. In 2020 our budget anticpates cuts to awarded state funding through the governor's budget withholding at 10-20%. To address our likely shortfall,we have reached out to new and former funders like the National Fish and Wildlife Foundation to try to develop new initiatives that further both the funders'and BIISC missions. We were relieved and gratified to see that DLNR listed funding for the Invasive Species Committees among its top five priorities and key relationships in their budget request. While we realize we may never get close to the over$1 M per year Maui County provides to their island invasive species committee,we hope that the County of Hawaii will see the value in steadily increasing support for our program over time. In general,while we always need new sources of funds,we seek to maintain a steady,reliable program and to improve public policy to prevent the introduction of new species,rather than continually growing our program. 7. Program Objectives Using County Nonprofit Grant Program Funds: BIISC produces an annual action plan detailing benchmarks to be made each year towards the eradication of our target species. We were designated essential workers,and are grateful to have been able to continue our work at a safe distance from one another in the field.Requested funds, if awarded,will cover approximately 10%of the personnel costs toward achieving the following: 1.Buddleia madagascariensis:Complete initial suppression work on the two remaining untreated sites(50 acres).This requires cooperation with COH DPW or HDOA to post entry signage allowing entry,due to absentee landowners.Survey and treat any resprouts at eight mid-phase sites near Hawaii Volcanoes National Park. Monitor(revisit and check on)ten sites that are in completion phase. 2.Cotoneaster pannosus:Survey and treat re-sprouts at 6 sites totaling over 1,000 acres.Monitor 2 sites in completion phase. 3. Ilex cassine:Survey and treat keiki plants on 302 acres at the two known island sites. 4.Markhamia lutea:Visit all sites twice to hand-pull seedlings.No known remaining mature plants,small areas. 5. Pereskia aculeata(vana vine):Conduct second or third sweeps in nine sites. Conduct initial suppression in two sites. 6.Photinia davidiana:Complete 300 acres of Photinia survey and control,including 150 acres each on federal and state land.Work on federal land is 100%federally funded. 7.Continue to assist the watershed partnerships,where feasible,with control of widespread,high impact species including gorse. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) We use the density of mature and immature plants(#of plants per acre)to track progress through four phases of control. Mature plant density--unknown Phase 1:initial survey and suppression Mature plant density>ten plants per acre Phase 2:Control Mature plant density<ten plants per acre and Immature plant density>ten plants per acre on two visits Phase 3:Control Immature plant density<ten plants per acre Phase 4:Monitor None found for two reproductive cycles Pau!Send out the press release! A simple way to report progress is to share the number of sites moved ahead in phase of control. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 305,811 290,000 27,000 Professional Fees 0 0 Operations 28550 25,000 Supplies 10,000 9,500 Equipment 0 0 Other: Office rent, utilities, etc 24,444 20,000 Other: 10,000 8,000 Other: Other: Other: Indirect/Admin Fee 10% 37,880 35,250 3,000 TOTAL 416,685 387,750 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ® Member or members of the Council ® Staff appointed by a member of the Council fl The Mayor • The Managing Director ® The Director of Finance ® The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: IX! If no conflicts exist, check here. Larry M - Komafa, Pr2shien/ 01-28-2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aciency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01-28-2021 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: BIISC Invasive Species Early Detection and Rapid Response Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Buddleia Control (Each projected result is 10% of annual workplan) 15 acres 2. Cotoneaster Control 100 acres 3. Ilex Control 30 acres 4. Markhamia Control 200 plants 5. Pereskia Control 50 acres 6. Photinia Control 15 acres 7. Gorse and/or other high profile species in watersheds 120 acres TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $27,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: Admin Fee $ 3,000 TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Big Island Resource Conservation & Development Council Education in Experiential Learning on Tropical Plants 23 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Developement Council Program Name:Education in Experiential Learning on Tropical Plants Agency Director: Larry M. Komata, President Phone No.:(808 )961 -6425 Contact Person: Brandi Milare, Program Manager Phone No.:(808 )217 -7234 Mailing Address: Address: 200 Kanoelehua Ave. Address: PMB 285 City,SI,zip Hilo, Hawaii 96720 Facility Address: Address: 433 Ulu Mau PI. Address: City,sr,zip Hilo, Hawaii 96720 Email Address: bircd1@gmail.com Fax No.: ( ) - Accountant/CPA: N/A Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) El Puna ❑ Hamakua ❑ North Kona Q South Hilo ❑ North Kohala ❑South Kona El North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑Youth El Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises El Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Developement Council Program Name: Education in Experiential Learning on Tropical Plants 1. Prior Year Award of CountyNonprofitProgram Grant Pro ram Funds: FY 18-19 FY 19-20 FY 20-21 N/A $4076 2.Agency Mission Statement: Big Island Resource Conservation and Development Council is a registered non-profit organization within the State of Hawaii, operating since 1975. Our mission is to assist people of the Big Island in achieving sustainable development while caring for, and appreciating their natural environment. We aim to ensure broadened economic opportunities, enriched communities, and better lives. The Vision of Big Island RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawai'i. As an organization,we strive to identify a concern, organize a group, event, or program that will address the concern, develop a plan of action, all while simultaneously seeking a funding source. This framework produces partnerships formed throughout the community,with government agencies, and with other foundations or corporations. It is truly rewarding to see the positive change that comes about when people gather together, share a common goal, and are able to use their individual platforms to work toward success. 3. Program Description: The College of Agriculture,Forestry,and Natural Resource Management(CAFNRM)is part of the University of Hawai'i at Hilo(UH-Hilo).The main objective of CAFNRM is to prepare students for a broad and full understanding of basic factors involved in production,management,processing,distribution,marketing,sales,and services in the field of agricultural sciences.To achieve this goal,CAFNRM offers the Bachelor of Science degree(BS)in four areas of specialization: Animal Science;Aquaculture;Tropical Horticulture,and Tropical Plant Science&Agroecology. In order to prepare students for immediate careers in agriculture,as well as further graduate study,the program blends comprehensive classroom instruction with practical,technology-based education through use of the University of Hawai'i at Hilo Agricultural Farm Laboratory.On 110 acres in Pana'ewa,five miles south of the main campus,students can experience putting theory into practice with hands-on learning in various enterprises such as hydroponics,floriculture plants,forestry,vegetables,sustainable agriculture,livestock production,equine science,beekeeping,tropical fruit,and aquaculture(https://hilo.hawaii.edu/academics/cafnrm/). Recently,CAFNRM is being extending its hands on education through experiential learning on tropical plants such as crops,vegetables,fruits and omamentals and encourage students to present their project findings at scientific meetings such as annual CAFNRM symposium.This situation could help to uplift the overall educational standard of UH-Hilo. 4.Total Budget& Position Count: Total Program Budget: 9000 Total Program Position Count: 1 Total Agency Budget: 38865 Total Agency Position Count: 1 paid/11 volunteer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Developement Council Program Name: Education in Experiential Learning on Tropical Plants 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(this proposal) 10,000 TOTAL: 10,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As mentioned,the CAFNRM educates through experiential learning and hands on projects.As a part of class/laboratory, students involve in growing plants and selling college grown plants(such as poinsettia)to college/university community. Collected monies are used in purchasing educational supplies. 7. Program Objectives Using County Nonprofit Grant Program Funds: The broad objective of this project is to involve students in experiential learning in Hawaii.The specific objective of this proposal is to educate undergraduate students on crop,vegetable and flower husbandry practices through student led research projects. In this project,undergraduate students of UH-Hilo will be involved.Students will plan and develop individual and/or group research project(s)and investigate the effects of plant growth-related factor(s)on selected plant. Each treatment of selected project will be replicated and experimental units(pots/plots)will be arranged in randomized complete blocks. Students enrolled in an agriculture/horticulture course such as Principles of Horticulture(HORT 262)will be involved in this proposed experiential learning project.Activities such as seed sowing,seedling transplanting,experiment pot/plot setting, labeling,fertilizer applying,data recording,harvesting,data analyzing and presenting will be performed.Potential economic viability of selected plant/production will be assessed.Project findings will be presented at an annual CAFNRM symposium at UH-Hilo. It is expected that 15 students will be directly involved in this proposed experiential learning. Moreover,about 300 CAFNRM/UH-Hilo community members will review this work at the CAFNRM symposium.The findings of this project could benefit the farmers,students,researchers,extension workers,educators and the entire agriculture community of Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Developement Council Program Name:Education in Experiential Learning on Tropical Plants 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Student number directly involved in proposed project 15 Number of student projects 4 Number of poster or oral presentations at a scientific meeting(such as CAFNRM symposium)or in class 4 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $0.00 $0.00 $0.00 Professional Fees $0.00 $0.00 1000.00 Operations $0.00 $0.00 $0.00 Supplies $0.00 $0.00 $9000.00 Equipment $0.00 $0.00 $0.00 Other: Other: Other: Other: Other: TOTAL $0.00 $0.00 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Developement Council Program Name:Education in Experiential Learning on Tropical Plants 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council O Staff appointed by a member of the Council O The Mayor a The Managing Director O The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: '0 If no conflicts exist,check here. Art•`-°<' 01 -28-2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Developement Council Program Name:Education in Experiential Learning on Tropical Plants 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Developement Council Program Name:Education in Experiential Learning on Tropical Plants 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. f14(fr7-4-"C--- 01 -28-2021 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Developement Council Program Name:Education in Experiential Learning on Tropical Plants 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Student number directly involved in proposed project 15 Number of student projects 4 Number of poster or oral presentations at a scientific meeting(such as CAFNRM symposium)or in class 4 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0.00 Professional Fees 1000.00 Operations $0.00 Supplies $9,000.00 Equipment $0.00 Other: Other: Other: Other: Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Big Island Resource Conservation & development Council Mauna Kea Watershed Alliance 24 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance Agency Director: Larry Komata, President Phone No.:(808) 961-6425 Contact Person: Brandi Milare Phone No.:(808) 217-7234 Mailing Address: Address: 200 Kanoelehua Avenue, PMB 285 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 433 Ulu Mau Place Address: City,sr,zip Hilo, HI 96720 Email Address: bircdl@gmail.com Fax No.: N/A Accountant/CPA: N/A Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $a o, 000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna 0 Hamakua ❑ North Kona •South Hilo ❑ North Kohala ❑South Kona ❑■ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth []Victims of Crimes 0 Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities El Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $4700 0 0 2.Agency Mission Statement: The Mission of the Big Island RC&D Council is to assist the people of the Big Island in achieving sustainable development while caring for,and appreciating their natural environment;to ensure broadened economic opportunities, enriched communities, and better lives. The Vision of the Big Island RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawai'i. The Vision of the Mauna Kea Watershed Alliance (MKWSA)is to protect and enhance watershed ecosystems, biodiversity and resources through responsible management,while promoting economic sustainability and providing recreational, subsistence, educational and research opportunities. The MKWSAMemorandum of Understanding (MOU)provides for Members to work together across the MKWSA landscape to sustain adequate quality and quantity of water and to protect and enhance native flora and fauna for now and future generations. 3. Program Description: The Mauna Kea Watershed Alliance is one of ten watershed partnerships across Hawaii Pae'Aina spanning almost every high mountain in Hawaii,the Hawaii Association of Watershed Partnerships(HAWP).The HAWP comprises ten island based Watershed Partnerships that work collaboratively with more than 74 public and private partners on five islands to protect over 2.2 million acres of vital forested watershed lands. The Mauna Kea Watershed Alliance MOU includes the Department of Land and Natural Resources, Parker Ranch, Department of Hawaiian Home Lands, Hakalau Forest National Wildlife Refuge,Kukaiau Ranch,Queen Lilu'okalani Trust, and Kamehameha Schools.The affiliate partners include the Pacific Islands Fish and Wildlife Office,The Nature Conservancy, and US Forest Service Institute of Pacific Islands Forestry.The partnership lands span 416,000 acres on Mauna Kea. The Alliance staff conduct watershed management activities on Mauna Kea including hosting out-planting activities like native seed collection, environmental education, growing and planting native trees and shrubs in natural areas. Currently due to the economic impacts of COVID-19 our programs have had a 20-30%reduction in State of Hawaii general funds and it is expected that reductions will continue for a few more years. The Mauna Kea Watershed Alliance requests funds to procure native trees and shrubs from local vendors to plant at our 1,100-acre management unit on the eastern slope of Mauna Kea. 4.Total Budget&Position Count: Total Program Budget: 414,667 Total Program Position Count: 8 Total Agency Budget: $38,865 Total Agency Position Count: 1 paid/11 volunteers EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii Watershed Partnerships Program 194,000 State of Hawaii Capital Improvement Projects 239,000 Department of Hawaiian Home Lands 174,000 Nonprofit funding 22,000 TOTAL: $629,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The plan is to develop relationships with new funding organizations to diversify funding support and apply for more grants from federal and private organizations that want to contribute to on-the-ground action that secures freshwater quality and quantity. The service we provide through watershed management activities protects and restores source waters,current management is at the headwaters for the Wailuku River located at approximately 5,500 feet elevation and protects six million gallons per day of freshwater recharge. In recent years we have also developed a strong relationship with the Natural Resource Conservation Service(NRCS)that supports watershed management projects through cost share programs, this year we will start to plant native trees at our management unit in partnership with the NRCS. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Mauna Kea Watershed Alliance will procure native plants from Hawaii County plant nurseries for out-planting at the 1,100-acre Waipahoehoe Management Unit. These include native trees and shrubs such as Acacia koa(koa),Sophora chrysophylla (mamane),and Dodonaea viscosa (aali'i). These plants eventually grow to a multi-canopied forests capable of slowing and capturing water from mists and rain. At an average of$4 per native plant this equates to 4,500 native plants. Additionally, we will engage at least four youth and young adults in watershed management and support local jobs and internship programs positions with matching funds. These positions include summer intemships, Hawaii Youth Conservation Corps, and temporary management hires. They will assist with caring for the plants while hardening at Waipahoehoe and with planting. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeosuring what happens for the Participants after they have participated in your program?Describe,be specific.) Procure native plants from Hawaii County nurseries 4,500 plants Attach additional pages as necessary. 9.TABLE II: FY 20-21 P121-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 262,000 Professional Fees 0 Operations 105,000 Supplies 39,000 18,000 Equipment 0 Other: BIRCD operational support 2,000 Other: Other: Other: Other: TOTAL 406,000 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council O The Mayor ® The Managing Director O The Director of Finance JJ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: X J If no conflicts exist, check here. AfrA".%CP President 01-28-2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood thele requirements. AlfrA-#"C 01-28-2021 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Mauna Kea Watershed Alliance 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Procure native plants from Hawaii County nurseries 4,500 plants TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies 18,000 Equipment Other: BIRCD operational support 2,000 Other: Other: Other: Other: TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Big Island Resource Conservation & Development Council Nutrition Grown Farming Educational Program 25 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:IBig Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program Agency Director: Larry M. Komata, President Phone No.:(808) 961-6425 Contact Person: Brandi Milare, Program Manager Phone No.:(808) 217-7234 Mailing Address: Address:200 Kanoelehua Ave. Address:PMB 285 city,sr,zip Hilo, Hawaii 96720 Facility Address: Address: 433 Ulu Mau PI. Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bircd1@gmail.com Fax No.: ( ) Accountant/CPA: N/A Phone No.:( ) Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) ■❑ Puna ❑i Hamakua ❑■ North Kona 0 South Hilo Q North Kohala 0 South Kona 0 North Hilo ❑■ South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes O Culture and the arts ❑Aged 0 Victims of Health or Social Crises O Needs of the poor 0 Physical/Emotional Disabilities • Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: Nutrition Grown Farming Educational Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $4058 $10,550 2.Agency Mission Statement: Big Island Resource Conservation and Development Council is a registered non-profit organization within the State of Hawaii, operating since 1975. Our mission is to assist people of the Big Island in achieving sustainable development while caring for, and appreciating their natural environment. We aim to ensure broadened economic opportunities, enriched communities, and better lives. The Vision of Big Island RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawai'i. As an organization,we strive to identify a concern, organize a group, event, or program that will address the concern, develop a plan of action, all while simultaneously seeking a funding source. This framework produces partnerships formed throughout the community,with government agencies, and with other foundations or corporations. It is truly rewarding to see the positive change that comes about when people gather together, share a common goal, and are able to use their individual platforms to work toward success. 3. Program Description: Scientific studies show significant losses(up to 70%)of soil mineral content and food nutrient content over the past 80 years. Dr.Jana Bogs(PhD horticulture/food science)developed methods to restore soil and food nutrient content, Nutrition Grown foods have greater nutrient content than typically grown foods,even organically grown,due to a focus on improving nutrient content. Nutrition Grown food nutrient values are approximately double as compared to the USDA food nutrient database values. Growing methods are environmentally friendly,and may be certified organic. Other benefits of using these growing methods include greater yields,better flavor,longer shelf life,increased pest and disease resistance, and improved marketability. Additional information may be seen at www.beyondorganicresearch.com. We propose to continue offering an interactive,online educational program to educate nine more Big Island farmers about Nutrition Grown methods and to assist them in implementing these methods. (Our program recruitment efforts for 2020-2021 resulted in more applicants than we could support.)The course consists of 19 half-hour teaching videos,pre- and post-comprehensive soil analyses,plant tissue analyses for food nutrient content compared to USDA values,online group calls to further teach and answer questions,and on-site consulting and materials as necessary to implement the program.Some funding is allocated for soil amendments/fertilizers,which is needed to encourage participation and implementation. The students will grow 200 square foot trial plots as Nutrition Grown projects to compare to their current cropping methods.They will keep records of crop progression from soil preparation through harvest,along with photo documentation. Data will be posted online and shared by Dr.Bogs for additional educational purposes. Each student successfully completing the course will receive a certificate. 4.Total Budget&Position Count: Total Program Budget: $30,000 Total Program Position Count: 1 Total Agency Budget: $38,865 Total Agency Position Count:1 Paid / 11 volunteer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name: Nutrition Grown Farming Educational Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii NonProfit Grant 30,000 In Kind 10,000 TOTAL: 40,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to apply to other funding sources,such as The Healy Foundation and the Hawaii Community Foundation,to be able to include more farmers. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goals and objectives related to the request Goals- 1)Teach Nutrition Grownim farming techniques to nine(9)Big Island food producers primarily via online methods,but also including on-site, hands-on application education. 2)Establish Nutrition Grown trial plots on food producers'land for educational purposes. 3)Perform comprehensive pre-and post-soil analyses,and plant tissue nutrient analyses with comparisons to USDA values documented. 4)Share information and knowledge gained through online and offline resources. Objectives- 1)Allow food producers to learn farming techniques with hands-on farming trials which improve crop success and food quality with environmentally-friendly methods. 2)Make more and better quality foods available to Hawaii residents from locally-grown,environmentally-friendly sources. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Effectiveness of the program may be seen in: Projected results: 1)Number of students completing the program 1)Nine 2)Students'responses on evaluation questionnaire 2)Students value what they learned 3)Differences in soil quality parameters compared over time(pre-and post-intervention 3)Overall improvement in soil parameters 4)Increases in food nutrient content as compared to USDA Food Nutrient Database values 4)Significant increases over USDA values 5)Crop parameters tracked by students regarding crop health,yields,flavor,appearance 5)Favorable results on all parameters Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages n/a 15,900 15,900 Professional Fees Fiscal Sponsor Admin Fee _ 3,000 3,000 Operations 1,800 1,800 Supplies 2,700 2,700 Equipment Other: Travel Expenses 2,100 2,100 Other: Lab Fees/Postage 4,500 4,500 Other: Other: Other: TOTAL 30,000 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council • The Mayor ® The Managing Director 071 The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: VI If no conflicts exist, check here. Larry M. Komata, President 01-28-2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Big Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 . County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:IBig Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 4X14&tACI---- 01-28-2021 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Big Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of students completing the program Nine Students responses on evaluation questionnaire Students value whet they learned Differences in soil quality parameters compared over time imp.vement eon ler Increases in food nutrient content Significant increase Crop parameters tracked by students regarding crop health,yields,flavor,appearance Favorable all parameters TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 15900 Professional Fees 3000 Operations 1800 Supplies 2700 Equipment Other: 2100 Other: 4500 Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Boy Scouts of America Hawaii Island Scouting Program -Scoutreach 38 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Boy Scouts of America Program Name:Hawaii Island Scouting Program - Scoutreach Agency Director: Jesus Lopez Phone No.:(808 ) 595 —0859 Contact Person: Jason Ontiveros Phone No.:(808 ) 959 —0079 Mailing Address: Address: PO Box 5327 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 580 Stainback Highway Address: City,s-r,zip Hilo, HI 96720 Email Address: jason.ontiveros@scouting.org Fax No.: (808 ) 959 —3568 Accountant/CPA: Phone No.:(808) 521 —3962 Firm (if applicable): KKDLY LLC Mailing Address: Address: Topa Financial Center 745 Fort Street Suite 2100 city,sr,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna Hamakua ❑■ North Kona n South Hilo • North Kohala n South Kona ❑■ North Hilo j South Kohala • Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns n Youth n Victims of Crimes n Culture and the arts ❑Aged Victims of Health or Social Crises Needs of the poor n Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 10,473 17,500 2. Agency Mission Statement: Aloha Council, Boy Scouts of America's vision is to positively impact the lives of Hawaii's youth through Scouting's leadership development and outdoor education programs. Our work supports the Boy Scouts of America mission to prepare young people to make ethical and moral choices over their lifetimes by instilling in them the values of the Scout Oath and Law. The Scout Oath: On my honor, I will do my best to do my duty to God and my Country and to obey the Scout Law;to help other people at all times;to keep myself physically strong,mentally awake and morally straight. The Scout Law:A Scout is trustworthy, loyal, helpful,friendly, courteous, kind,obedient, cheerful,thrifty, brave,clean,and reverent. Boy Scouting was organized in the Territory of Hawaii in 1911 with the formation of the Honolulu Council which oversaw Scouting throughout the Hawaiian Islands. In 1919,the Kilauea Council was formed on the Island of Hawaii and remained in existence until 1972 when it merged with the Aloha Council. Throughout a storied century, boys have been exposed to nature, outdoor adventures and skill-building and along the way learned teamwork, leadership, independence and resilience. 3. Program Description: Scoutreach is committed to enriching the lives of at-risk youth by ensuring that quality programs are available to them. While we seek to serve youth throughout the Big Island,the Scoutreach program will place specific emphasis on expanding support to youth living in Hamakua, Puna and Kau. Our program partners with public schools and traditional volunteer units(Troops&Packs)to provide access and opportunity to serve at-risk youth.Select schools are located in neighborhoods where many families live at or below poverty levels,where public schools are not yielding adequate yearly progress results,and youth have limited opportunities for positive alternatives via self-development programs.50%or more of the students are on Free/Reduced lunch programs. Many of the schools are listed as a Title 1 school which indicates a greater need for academic support.Scoutreach provides after-school programs Monday through Friday during the school year and each youth(all genders)attends with their peer group we call"Dens"or"Patrols"based on their grade level. We seek to partner and have programs at school sites because it increases the likelihood of attendance, links after-school instruction to the school day,takes advantage of existing infrastructure and reduces transportations costs. Being at the school opens up access to children of working parents,for whom lack of transportation to off-campus activities is a barrier to to participation.This structure enables partner relationship between Scouting,teachers and administrators. Through positive peer group interaction&adult guidance,youth experience advancement through adventures that are age appropriate and engaging. Leadership, character, life skills,teamwork,self confidence are proven outcomes to the Scouting program. 4. Total Budget& Position Count: Total Program Budget: 91,700 Total Program Position Count: 3 Total Agency Budget: 2,193,120 Total Agency Position Count: 20 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate HEI Charitable Foundation 5,000 Annual FOS Campaign(General Operating) 15,000 Product Sales(Popcorn and Camp Card Sales) 10,000 TOTAL: 30,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Expanding outreach to at-risk youth is a top priority of the Aloha Council Board. The council board recognizes that there are many barriers to participation and is working vigilantly to overcome these obstacles. Funding will remain a critical role in ensuring that services and activities will continue to benefit the community through Scouting. In order to sustain activities beyond the County Grant,we will look at other avenues within traditional scouting units where leadership is well established. We would reach out to families of youth participating in the Scouting program who may be able to dedicate a small amount of money to help support the program their child is benefiting from. We will invite sponsoring organizations to budget some money to help offset some of the program expenses. We will engage our scouts to do product sales to nelp offset costs as well. The product sales will be supervised by the unit leaders and managed through a unit program budget plan. The product sales will be part of the council sponsored events to include Camp Card Sales and Popcorn Sales. Our Scoutreach committee will actively reach out to the community leaders,other non profits and businesses to secure support and create partnerships. 7. Program Objectives Using County Nonprofit Grant Program Funds: Through active and consistent participation in the Scouting program,youth throughout the Big Island will display healthy social and emotional development and improve academic confidence and performance. Our Scouting objectives include: 1. Participation: Increase participation in all Scouting programs to impact more at-risk youth. 2. Community Collaboration: Collaborate with community organizations and elementary schools to conduct Scouting programs to increase reach within the area. Hire and train program staff to serve as mentors for at-risk youth. 3.Skill Proficiency:Teach and create curriculum so that Scouts may learn and practice new things, life skills and values. 4. Outdoor Experiences: Expose Scouts to outdoor experiences by providing off-site excursions since opportunities to camp,family hike, practice outdoor skills and learn about nature are limited. Include entire families or weekend dates to encourage greater attendance. 5. Community Service: implement community service programs so members can learn the value of caring for and giving back to their neighborhoods. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) %Youth retention in Scouting >60% %of Youth participating in Scouting adventures and advancement >40% %of Youth participation in Resident Camping Experience >30% #of service hours performed in the community >400 hours Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 49,100 19,500 Professional Fees Operations Supplies 6,000 5000 Equipment Other: Assistance to Individuals; Activities & Camping Fee 15,000 10,000 Other: Membership Fee and Insurance Coverage 21,600 17,280 Other: Other: Other: TOTAL 91,700 51,780 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑f Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director 17 The Director of Finance n The Corporation Counsel, the Assistant Corporation. Course!, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. Scout Executive/CEO 1/29/2021 Signature f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded agrant from the Countyof Hawai`i I (we) understand and will comply with the requirement pV q to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/29/2021 Signa re of Authorized Person Date Scout Executive/CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boy Scouts of America Program Name: Hawaii Island Scouting Program - Scoutreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result % Youth Retention in Scouting >60% % of Youth participating in Scouting adventures and advancement >40% % of youth participating in Resident Camping Experience >30% # of Service hours performed in the community >400 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 19,500 Professional Fees Operations Supplies 5,000 Equipment Other: Assistance to individuals; fel 10,000 Other: Membership Fee & Insuraj 17,280 Other: Other: Other: TOTAL 51,780 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Boys Girls Club of the Big Island Community Meal Support for Income-Challenged Youth, Kupuna, and Families 39 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip. Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $100,000.00 Geographical Areas To Be Served: (One or more can be checked) ■❑ Puna ❑ Hamakua 0 North Kona ■❑South Hilo ❑ North Kohala ❑■ South Kona 0 North Hilo ❑South Kohala Q Ka'u • Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts ❑ Aged ❑Victims of Health or Social Crises O Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $16,375.00 $15,830.00 $33,750.00 2.Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment."For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:65%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 80%of BGCBI youth members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low- cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: The"Community Meal Support for Income-Challenged Youth, Kupuna, and Families"program will help support those in need with daily hot meals, free-of-charge.A total of 850 meals are produced each day out of two (2) BGCBI kitchen operations based in East and West Hawaii (Hilo & Kona).The"hot meals"are prepared, cooked, plated, and individually sealed by BGCBI kitchen staff each day and then delivered to identified homeless and low-income level populations not able to secure adequate daily nutrition, which affects their ability to maintain physical health. For homeless and poverty- level households residing throughout Hawaii County's geographically spread apart rural area communities,the major barrier to access critical social service resources is transportation access.Through the program's meal shuttle delivery, BGCBI will bring the critical resource(hot meals and nonperishable food items)to the rural area community and direct to the individual and household location of those needing nutritional supplementation. BGCBI will continue to provide meals for Hawaii Islands most at-risk and vulnerable populations (i.e. homeless and low-income level individuals and families). The program will provide supplemental food access and food distribution direct to homeless and low-income level individuals and family households in the form of daily(Monday-Friday) "hot-meals"and food items, free-of-charge, throughout Hawaii County. BGCBI has successfully delivered over 174,126 full hot meals and 67,680 snacks since the inception of our meal program in June 2017. Within the first few days of the meal program starting, staff and parents noticed behavioral changes in the youth with an increased focus, willingness to learn, and higher respect for others. (Please see the attached for a continuation of description.) 4.Total Budget & Position Count: Total Program Budget: 294,605 Total Program Position Count: 5 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Community Meal Support for Income-Challenged Youth, Kupuna, and Families The meal program has fed our Hilo youth for almost 3 years and BGCBI is ready to expand its meal services to feed more youth, kupuna, and families. With a dedicated staff and strong community and business partnerships, the expanded meal program will be able to serve more youth, kupuna, and families. BGCBI has received high demand from families to expand the meal program, and now with the experience and staff in place, we are working hard to meet community demands. Clubs will continue to receive healthy snacks. BGCBI recognizes that many local Big Island youth often receive a full meal only at school, as many families are not able to provide daily nutritious meals due to economic challenges. The national child poverty rate is 22% and the State of Hawaii rate is 14%. The Big Island's child poverty rate is 26%, more than double Honolulu County's 12% average (US Census, 2013). Additionally, Hawaii County, at 66%, has the highest rate of students receiving free or reduced school lunch, which is significantly higher than the combined State average of 50%. Organization-wide, 80% of the enrolled BGCBI youth are currently receiving free or reduced school lunches. County of Hawaii Nonprofit Grant Application FY2O21-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $100,000 Full Calabash Fund $50,000 Private Community Individuals $35,000 TOTAL: $185,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Electric Industries,The Atherton Family Foundation, Private Community Individual, Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo 7. Program Objectives Using County Nonprofit Grant Program Funds: Serve an estimated 800 meals daily throughout the year EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of estimated meals to be served daily for the 2021-2022 year 800 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 67,500 Professional Fees 35,738 36,453 Operations 316,577 322,909 10,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: Program Food 20,043 20,444 20,000 Other: Transportation Costs 29,657 30,250 Other: Equip. Lease - Copier & Postage Meter 10,611 10,823 Other: Miscellaneous Expenses 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 100,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council ❑I The Mayor OI The Managing Director OI The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: R If no conflicts exist, check here. /-- 01/29/2021 Signat - • " 1 uthorized Person (spey title) /121 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 01/29/2021 Signatur• .F uthorized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Community Meal Support for Income-Challenged Youth,Kupuna,and Families Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of estimated meals to be served daily for the 2021-2022 year 800 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 67,500 Professional Fees Operations 10,000 Supplies 2,000 Equipment 500 Other: Program Food 20,000 Other: Other: Other: Other: TOTAL 100,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Boys Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna and Families 40 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona • ❑South Hilo n North Kohala n South Kona n North Hilo n South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) LI Educational concerns LI Youth n Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑i Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Boys & Girls Club of the Big Name: Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A $16,830.00 $21,250.00 2.Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment"For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:65%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 80%of BGCBI youth members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low- cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: The proposed program"Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families"will provide daily shuttle transportation services (free-of-charge)for income-challenged youth (i.e. homeless youth and youth from poverty and low-income family households), providing access to BGCBI hosted after school youth development programs that are located in the communities of Hilo, Pahoa, Na'alehu-Ocean View. For homeless and poverty-level households residing throughout Hawaii County's geographically spread apart rural area communities, the major barrier to access critical social service resources is transportation access.Through the program's meal shuttle delivery, BGCBI will bring the critical resource (hot meals and nonperishable food items)to the rural area community and direct to the individual and household location of those needing nutritional supplementation.As part of the program, BGCBI will provide free-of-charge supplemental food nutrition and delivery to identified homeless and low- income level individuals and family households throughout Hawaii Island.Throughout the academic school year(10- months), BGCBI will provide free after school then shuttle transport from public and charter schools located in the Hilo, Puna, and Na'alehu area,to BGCBI youth development program site locations in Hilo, Pahoa, and Ocean View.Transport offerings will be targeted to support income-challenged youth that currently do not have transportation access to daily after school youth development resources and are currently going unsupervised after school. (Please see the attached for a continuation of description.) 4.Total Budget & Position Count: Total Program Budget: 109,000 Total Program Position Count: 4 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families Transportation is the major barrier and limiting factor in accessing critical support resources among economically disadvantaged families that reside in the rural area communities on Hawaii Island. Often specialized social-support services are affordable to income-challenged families but are not accessible for utilization due to the geographic distance of the service location and family transport limitations. Hawaii Island's current public transportation services often do not provide the frequency and consistency needed for struggling families to rely on and as a result, rural area income-challenged youth often go unsupervised and unattended after school not having affordable and available transportation to and from youth development services. While at BGCBI youth development programs, income-challenged youth (ages 6-17) will receive (free-of-charge): • Daily homework support and academic tutoring • Full evening meal and/or healthy snacks before going home • Organized and recreational sport opportunities • Healthy lifestyles activities, cultural programming, substance and alcohol prevention programming • Access to technology, computers, printing services, and internet Upon the conclusion of daily BGCBI support services, rural area community youth will be provided BGCBI operated transport shuttle services from programming site locations to their home residence (i.e. Ocean View youth shuttled home from BGCBI Ocean View Community Center site location). County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $50,000 Private Community Individuals $35,000 TOTAL: $85,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: The proposed program objective is to provide new and increased access for income-challenged youth that reside in the areas of Puna, Hilo, and Ocean View(i.e. homeless youth and youth from poverty and low-income level households).The youth can then participate, and utilize (M-F throughout the academic school yaer) critical youth development resources hosted by BGCBI.These resources will support their academic learning and educational achievement(through daily homework assistance/academic tutoring)and overall physical health (through the access of daily evening meals/healthy snacks provided). Daily transportation will be free of charge, and provided by BGCBI for youth ages 6-17 that are currently unavailable due to household financial limitations and daily access challenges(not having youth development program offerings within their geographic reach. This program will also provide critical needs resources and daily(M-F)nutritional supplementation of full hot meals directly to homeless or low-income level individuals or families, free of charge.Through the program's meal shuttle delivery, BGCBI will bring the critical resource(hot meals and nonperishable food items)to the rural area community and direct to the individual and household location of those needing nutritional supplementation.As part of the program, BGCBI will provide free-of-charge supplemental food nutrition and delivery to identified homeless and low-income level individuals and family households throughout Hawaii Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Please see the attached page#8: Program Performance Measures Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 25,000 Professional Fees 35,738 36,453 500 Operations 316,577 322,909 4,500 Supplies 38,081 38,843 Equipment 5,569 5,680 Other: Program Food 20,043 20,444 Other: Transportation Costs 29,657 30,250 20,000 Other: Equip. Lease - Copier & Postage Meter 10,611 10,823 Other: Miscellaneous Expenses 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 8 Table. Program Performance Outcomes: County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families Program Performance Measures Applicant Projected Results Daily (M-F) after school transport of 50 A minimum of 50 income-challenged income-challenged youth from Pahoa, youth will have a means of accessing Na'alehu, and Hilo based schools to essential after school youth development BGCBI's youth development programs services and resources daily (M-F) based in Pahoa town, Hilo town, and throughout the academic school year. Ocean View throughout the academic school year Youth participants will demonstrate 70% of youth improved study habits, better grades, and greater physical health. Youth participants will demonstrate that 70% of youth the meals and/or snacks they receive are beneficial to their nutritional supplementation needs Estimated daily meals to be served 800 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): CH Member or members of the Council In Staff appointed by a member of the Council ▪ The Mayor ▪ The Managing Director ▪ The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. '' � 01/29/2021 Signat es 4thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 01/29/2021 Signatu e of W horized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Please see the attached page #12: Program Performance Measures TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000 Professional Fees 500 Operations 4,500 Supplies Equipment Other: Transportation Costs 20,000 Other: Other: Other: Other: TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 12 Table. Program Performance Outcomes: County.Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families Program Performance Measures Applicant Projected Results Daily (M-F) after school transport of 50 A minimum of 50 income-challenged income-challenged youth from Pahoa, youth will have a means of accessing Na'alehu, and Hilo based schools to essential after school youth development BGCBI's youth development programs services and resources daily (M-F) based in Pahoa town, Hilo town, and throughout the academic school year. Ocean View throughout the academic school year Youth participants will demonstrate 70% of youth improved study habits, better grades, and greater physical health. Youth participants will demonstrate that 70% of youth the meals and/or snacks they receive are beneficial to their nutritional supplementation needs Estimated daily meals to be served 800 Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 41 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $70,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona g South Hilo ❑ North Kohala ❑ South Kona ❑■ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ■❑Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021- 2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 15,875.00 15,455.00 21,250.00 2.Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment."For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best, for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:67%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 77%of Hilo members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth"Boys& Girls Club of the Big Island(BGCBI) has supported income-challenged families(those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship, enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau,2010-2019).At BGCBI,our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4.Total Budget & Position Count: Total Program Budget: 245,804 Total Program Position Count: 8 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, Internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below),and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawaii Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 5. Program Funding Sources (identify all sources of funding appliedprogram):to this FY21-22 Revenue Source Estimate County of Hawaii $70,000 OJP $80,000 Rotary of South Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions, which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys.Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs. outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families, we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 43,000 Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: Telecommunications 20,043 20,444 1,000 Other: Fundraising & GET 29,657 30,250 Other: Equip. Lease - Copier & Postage Meter 10,611 10,823 500 Other: . Miscellaneous Expenses 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 70,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council OI The Mayor O The Managing Director []l The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I If no conflicts exist, check here. 01/29/2021 lad �Signa? Authorized Person (specify ti le) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 01/29/2021 Signat re o: - thorized Person Date � # L7Z,0 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school 80% of youth Participants will demonstrate a desire to participate in healthy lifestyle activities 70% of youth TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Other: Equip.Lease-Copier&Postage Meter 500 Other: Other: Other: TOTAL 70,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Boys & Girls Club of th Big Island, Kea'au Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 42 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $70,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna n Hamakua n North Kona ❑South Hilo n North Kohala n South Kona n North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) H Educational concerns Q Youth n Victims of Crimes H Culture and the arts ❑ Aged n Victims of Health or Social Crises Q Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment 1v1-111:21TA County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $15,875.00 $15,455.00 $22,500.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 69,years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:56%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 79%of Keaau members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth"Boys& Girls Club of the Big Island (BGCBI) has supported income-challenged families(those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship,enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau, 2010-2019).At BGCBI, our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4.Total Budget& Position Count: Total Program Budget: 120,997 Total Program Position Count: 4 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 r'VLIIDI-r A 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below), and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawai'i Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $70,000 OJP $80,000 Rotary of South Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions, which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys.Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs.outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in "Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families, we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. 1 Y 1-I I R IT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 43,000 Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: 20,043 20,444 1,000 Other: 29,657 30,250 Other: 10,611 10,823 500 Other:er: 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 70,000 *If applicable AXI-11111T A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council O The Mayor OI The Managing Director O The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. ./r, '' [� 01/29/2021 - Oodr Sign.' - iy Authorized Person (specify title) Date I VI-11RIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. FYI-IIRIT A i County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. / / 7'01( '-''"----------- 01/29/2021 Signatu - Authorized Person Date 641 Title/Position of/Authorized Person FYHIRIT A ai`i Nonprofit Grant Application of Haw p FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school 80% of youth Participants will demonstrate a desire to participate in healthy lifestyle activities 70% of youth TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Other: Equip. Lease-Copier&Postage Meter 500 Other: Other: Other: TOTAL 70,000 Additional Council directives regarding award: FXHIRIT R Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 43 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100•Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): . Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $70,000 Geographical Areas To Be Served: (One or more can be checked) El Puna Hamakua El North Kona ❑South Hilo ❑ North Kohala Q South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns ❑■ Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $15,875.00 $15,455.00 $40,000.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best, for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:35%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 73%of Kealakehe members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low- cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth"Boys& Girls Club of the Big Island (BGCBI) has supported income-challenged families (those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship, enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau,2010-2019).At BGCBI,our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4. Total Budget & Position Count: Total Program Budget: 175,128 Total Program Position Count: 4 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below), and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawai'i Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawai`i Nonprofit Grant Application FY2021-22 A enc Name: Boys & Girls Club of the Big Island, Kealakehe Club g Y Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 • Revenue Source Estimate County of Hawaii $70,000 OJP $80,000 Rotary of South Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services; in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions,which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys. Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs. outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families, we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A County of H wai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. • 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 43,000 .Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: 20,043 20,444 1 ,000 Other: 29,657 30,250 Other: 10,611 10,823 500 Other: 23,930 24,409 Other: TOTAL 1,691,731 70,000 *If applicable EXHIBIT A County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council ▪ Staff appointed by a member of the Council Ql The Mayor ▪ The Managing Director ▪ The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■M If no conflicts exist, check here. Li53 01/29/2021 Signatu - . thorized Person (spe fy title) Date EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. / 01/29/2021 . Al Signatur• of ie horized Person Date Ity Title/Position of Autho ized Person EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school • 80% of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70% of youth TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages • 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Other: Equip.Lease-Copier&Postage Meter 500 Other: • Other: Other: TOTAL 70,000 Additional Council directives regarding award: EXHIBIT B Boys & Girls Club of the Bug island, Ocean View Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 44 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $70,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑l Youth - ❑Victims of Crimes 0 Culture and the arts ❑ Aged ❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment FXHIRIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 n/a n/a $22,500.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational,character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:81%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 81%of Ocean View members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low- cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth" Boys& Girls Club of the Big Island (BGCBI) has supported income-challenged families(those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship, enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household. The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau, 2010-2019).At BGCBI, our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4. Total Budget & Position Count: Total Program Budget: 106,069 Total Program Position Count: 3 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 1 V 1-I I R I T A 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below), and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawai'i Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $70,000 OJP $80,000 Rotary South of Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. • BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions, which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys.Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs. outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families,we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. rvuinI-r n • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 43,000 Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: Telecommunications 20,043 20,444 1 ,000 Other: 29,657 30,250 Other: 10,611 10,823 500 Other: 23,930 24,409 Other: TOTAL 1,658,560 1 ,691,731 70,000 *If applicable CVLIIDIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Boys & Girls Club of the BigIsland, Ocean View Club Agency Name.. Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council OI The Mayor O The Managing Director OI The Director of Finance QI The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■n If no conflicts exist, check her-. if& ‘41/f) l! 01/29/2021 Signet re of jthorized Person (specify title) / Date cvuIDIT A nof Hawaii Nonprofit Grant Application County p FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. CVIJIDIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. / //1 01/29/2021 IIISignatur. s )horized Person Date c CjiAL/t daI1 Title/Position of Authdrized Person CVUIQIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school 80% of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70% of youth TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Other: Equip.Lease-Copier&Postage Meter 500 Other: Other: Other: TOTAL 70,000 Additional Council directives regarding award: I=VLIIRIT R Boys & Girls Clue of the Big Island, Pahala Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 45 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5534 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $70,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala Q Kai) Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes • Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $15,875.00 $15,455.00 $24,750.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:93%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 80%of Pahala members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth" Boys& Girls Club of the Big Island (BGCBI) has supported income-challenged families(those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship, enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau, 2010-2019).At BGCBI, our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4.Total Budget& Position Count: Total Program Budget: 133,866 Total Program Position Count: 3 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below), and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawai'i Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support, Youth Development Programming for Income- Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $70,000 OJP $80,000 Rotary of South Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions,which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys.Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs. outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families, we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How ore youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201o 921 43'000 ,aKa Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: Telecommunications 20,043 20,444 1,000 Other: Fundraising & GET 29,657 30,250 Other: Equip. Lease - Copier & Postage Meter 10,611 10,823 500 Other: Miscellaneous Expenses 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 70,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council Staff appointed by a member of the Council QI The Mayor QI The Managing Director The Director of Finance DI The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 01/29/2021 Signat - . - uthorized Person (specititle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 01/29/2021 Signatur: of ' "thorized Person Date e/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school 80% of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70% of youth TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Equip.Lease-Copier&Postage Meter 500 Other: Other: Other: Other: TOTAL 70,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 46 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: shad@becbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City, ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $70,000 Geographical Areas To Be Served: (One or more can be checked) ■❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns El Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises g Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $15,875.00 $15,455.00 $22,500.00 2.Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment programs to guide youth toward being and doing their best, for just$10 per year.Annually, BGCBI serves 1,000 youth in rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:88%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 97%of Paoha members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth" Boys & Girls Club of the Big Island (BGCBI) has supported income-challenged families(those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship, enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau, 2010-2019).At BGCBI, our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4. Total Budget& Position Count: Total Program Budget: 131,530 Total Program Position Count: 3 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, Internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below), and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawai'i Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $70,000 OJP $80,000 Rotary of South Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,000 Attach additional pages, if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions, which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys.Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs.outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families, we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 43,000 Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: Telecommunications 20,043 20,444 1,000 Other: Fundraising & GET 29,657 30,250 Other: Equip. Lease - Copier & Postage Meter 10,611 10,823 500 Other: Miscellaneous Expenses 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 70,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council Staff appointed by a member of the Council OI The Mayor OI The Managing Director O The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 1A16 �♦/ n 01/29/2021 Awe) , Signature i f Au''orized Person (specify titl Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there,is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. )1114 01/29/2021 Signatu /Authorized Person Date 1/YirliTt2._/\ Title/Position of Peuthorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school 80% of youth Participants will demonstrate a desire to participate in healthy lifestyle activities 70% of youth TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Other: Equip. Lease-Copier&Postage Meter Other: Other: Other: TOTAL 70,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources, Academic Support, Youth Development Programming for Income- Challenged Youth 47 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: Agency Director: Chad Cabral Phone No.:(808 ) 961 —5536 Contact Person: Chad Cabral Phone No.:(808 ) 961 —5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 —5534 Accountant/CPA: Debbie Perkins Phone No.:(808 ) 961 —5536 Firm (if applicable): Mailing Address: Address: 100 Kamakahonu Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of R.... equest for County Nonprofit Grant Program Funds: $70,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns Youth n Victims of Crimes n Culture and the arts ❑Aged ❑Victims of Health or Social Crises n Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $15,875.00 $15,455.00 $40,000.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment." For 69 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County, continuously focusing on educational, character development, nutritional supplementation, substance prevention, and health/wellness enrichment to guide youth toward beingand doingtheir best, forjust$10 peryear.Annually, BGCBI serves 1,000 youth in programs 1 Y rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View, Kealakehe-Kona, and Ulu Wini-Kona. BGCBI youth and the families we serve:80%report a combined annual income of$30,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally, 86%of Ulu Wini members report receiving free or reduced school lunches, a further indication of economic hardship. Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Critical Needs Resources,Academic Support, Youth Development Programming for Income-Challenged Youth"Boys& Girls Club of the Big Island (BGCBI) has supported income-challenged families (those that identify themselves as being homeless and struggling youth that are part of identified poverty and low-income level households) in providing key youth development activities and critical support resources after school that help to address the daily barriers associated with economic hardship, enhancing a child's overall ability to achieve, meet academic, personal, and career goals, and develop into a successful contributing adult member of the community.The proposed program will provide daily homework support and specialized academic tutoring and critical nutritional supplementation in the form of a full evening meal or healthy snacks to all BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.The requested funds are crucial to the successful implementation and daily delivery of essential snacks or cooked meals to all program site locations, along with providing daily homework support. Nationally, 1 in 7 children live in poverty(U.S. Census Bureau, 2010-2019).At BGCBI, our latest participant demographics indicate that 1 in 3 children live in a situation of poverty, and is well over the current national average. In supporting this program, Big Island youth will receive daily(Monday-Friday) after school/evening homework support and specialized academic tutoring and full hot meals or healthy snacks. Please see the attached for a continuation of description. 4.Total Budget & Position Count: Total Program Budget: 139,313 Total Program Position Count: 4 Total Agency Budget: 1,691,731 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 3. Program Description (Continuation): County Nonprofit Grant Application FY 2021-2022 Agency Name: Boys & Girls Club of the Big Island Program: Critical Needs Resources, Academic Support, Youth Development Programming for Income-Challenged Youth The following table communicates the specific project related items that are needed and how the funds will be utilized: Daily Nutritional Supplementation (Healthy snacks or full cooked evening meals): purchase of fresh fruits and vegetables; securing of needed protein sources for hot meals; kitchen operations: prepping, cooking and the plating/serving of daily snacks/meals, kitchen sanitation, utilities; daily transport of snacks or cooked meals to seven program site locations; purchase of paper-products and cleaning supplies; take home food containers for youth needing additional after program supplementation; disposal of daily post meal service trash. Daily Homework Study Support and Specialized Academic Tutoring: Educational Youth Specialists to facilitate daily youth homework support sessions; educational tutors to facilitate specialized daily tutoring in math, literacy, and science; homework support kits for youth: essential school supplies and backpacks; access to computers, Internet, copy machines, and printers to facilitate homework assignments and school projects; access to conducive study spaces, and providing adequate study furniture (i.e. youth size desks, chairs, desk lamps, and area rugs to host reading sessions). Project Learn: Literacy Enhancement includes storytelling, Hawaiian language and leisure reading, Wahi Pana (described below), and comprehensive discussions. This evidence-based comprehensive strategy allows the customization of a curriculum that fits the literacy needs of each Club. Site Coordinators engage in planning and developing activities that incorporate literacy in an interactive setting. This program aims to increase engagement and connection to the community and the island through Wahi pana curriculum and activities. The Wahi Pana program encourages and allows youth members to explore areas of historical landmarks in their community through research and storytelling. Youth will then share their research via video chat with youth at other Clubs. Participants will gain an understanding and knowledge of Hawaii Island beyond their own communities. The project expansion will ensure that youth will receive homework support and a full meal or healthy snack before going home for the day. The meals or snacks served will consist of vegetables, fruits, grains, protein, and milk. This proposed project is critical and essential in helping the Big Island community youth who qualify and rely on the free/reduced school breakfast and lunch program for daily nutrition and are unable to secure additional nutrition after the school day is over. Homework support and nutritional supplementation will be provided each afternoon, Monday-Friday, at all BGCBI youth development programs. County of Hawaii Nonprofit Grant Application FY2O21-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club g Y Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $70;000; OJP $80,000 Rotary of South Hilo $10,000 Private Community Individuals $20,000 Kamehameha Schools $75,000 TOTAL: $255,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues to advertise our services and our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services; in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth — Educational Support, Healthy Lifestyles, and Food Security. Below is a list of our current supporters: Hawaii Island United Way, Kamehameha Schools, Rotary Club of South Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among income challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set. BGCBI hosts wahi pana sessions, which is when each Club chooses historical sites in their areas and does research on it and shares that information with the other Clubs and youth, along with a creative art piece.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Participants in our reading program will take pre and post homework surveys.Through surveys, 50%of participants will show that they complete more of their homework during Club hours vs. outside of Club. An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club. 60%of Club members will participate in the homework support program. Since it is proven that the most effective programs include clubs, schools, and families, we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants surveys will show increased willingness to finish their daily homework 50%increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70%of youth • Participants show they complete more of their homework during their time at Club 50%increase Participants will access/utilize the supplemental nutritional program resource after school 80%of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70%of youth Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,178,354 1,201,921 43,000 Professional Fees 35,738 36,453 3,000 Operations 316,577 322,909 20,000 Supplies 38,081 38,843 2,000 Equipment 5,569 5,680 500 Other: Telecommunications 20,043 20,444 1 ,000 Other: Fundraising & GET 29,657 30,250 Other: Equip. Lease - Copier & Postage Meter 10,611 10,823 500 Other: Miscellaneous Expenses 23,930 24,409 Other: TOTAL 1,658,560 1,691,731 70,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council O The Mayor O The Managing Director OI The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: MI If no conflicts exist, check here. A vi/ _ i 01/29/2021 Ay Sign ; - c. . uthorized Person (spe y title) 46,9 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). Y I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 01/29/2021 AIM Signat 'authorized Person Date 3PJ2 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Boys & Girls Club of the Big Island, Ulu Wini Club Critical Needs Resources,Academic Support,Youth Development Programming for Income-Challenged Youth Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants surveys will show increased willingness to finish their daily homework 50% increase Number of participants in specialized literacy educational projects 20 Participants surveys communicate that the critical resources benefit their daily needs 70% of youth Participants show they complete more of their homework during their time at Club 50% increase Participants will access/utilize the supplemental nutritional program resource after school 80% of youth Participants will demonstrate a desire to participate in healthy lifestyles activities 70% of youth TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 43,000 Professional Fees 3,000 Operations 20,000 Supplies 2,000 Equipment 500 Other: Telecommunications 1,000 Other: Equip.Lease-Copier&Postage Meter 500 Other: Other: Other: TOTAL 70,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 [Brantley Center Inc. Job Skills Development Program 48 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Brantley Center, Inc Program Name:Job Skills Development Program Agency Director: Dareth Pung Phone No.:(808 )775 —7245 Contact Person: Dareth Pung Phone No.:(808 )775 —7245 Mailing Address: Address: Po Box 1407 Address: City,s-r,Zip Honoka'a Hawaii 96727 Facility Address: Address: 45-370 Ohelo Rd Address: City,ST,Zip Honoka'a, Hawaii 96727 Email Address: dboteilho@gmail.com Fax No.: (808 ) 775 —0211 Accountant/CPA: MGE Bookkeeping Phone No.:(808 ) 217 —1299 Firm (if applicable): Mailing Address: Address: Po Box 246 City,ST,zip Laupahoehoe, Hawaii 96764 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 30,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑■ Hamakua ❑ North Kona ❑South Hilo 0 North Kohala ❑ South Kona ❑■ North Hilo 0 South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts El Aged ❑Victims of Health or Social Crises • Needs of the poor 0 Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Brantley Center, Inc Program Name: Job Skills Development Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 14906.25 15125.00 13095.00 2.Agency Mission Statement: Our mission is to provide quality rehabilitation services that empower people with disanilities to participate indenpendently within his or her community. 3. Program Description: Brantley Center, Inc clients receive daily curb-to-curb transportation both to and from the Center free of charge. While at the Center clients receive a thorough job skills readiness assessment. Based on assessment results,they are given an appropriate service array. These services include job readiness courses,on the Job readiness training in the field, competitive employment placement services,and on the job follow up services.At the Center,clients have the opportunity to explore different jobs and skills ranging from janitorial skills,yard maintenance, landscaping,agriculture and hydroponic skills,green house maintenance,car wash and detailing, paper work organization,as well as small craft production. Clients are paid based on their productivity levels and are rewarded for increased and improved productivity. Once the necessary skills are obtained clients are then placed in competitive jobs within the community and continue to receive supportive follow up services for the initial six months of employment. The Job Skills Development staff and clients develop a strong relationship and rapport with community businesses and members leading towards community based vocational training as well as providing the public with and additional workforce. 4.Total Budget& Position Count: Total Program Budget: 145,900 Total Program Position Count: 7 Total Agency Budget: 390,000 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Brantley Center, Inc Program Name: Job Skills Development Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Auto Detailing Services 2,000 Janitorial Services 17,000 Yard Maintenance Services 111,300 • TOTAL: 130,300 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Brantley Center Staff and Board Members have made a collective and concerted effort to expand its fun development capabilities whether it be through pursuing new grants or coming up with fresh ideas on fundraising efforts. Brantley Center will increase revenues and continue to support the Job Skills Development Program through pursuing and securing more community contracts. Examples of currently secured contracts are numerous yard contracts within Honoka'a, County of Hawaii Hamakua District Police station car detailing contract and small craft production for different entities within our community.With the funding and intake of more clients we will be able to secure more contracts thus leading to a self sustained program. ' 7. Program Objectives Using County Nonprofit Grant Program Funds: If funds are awarded, Beginning July 01,2021 Brantley Center, Inc will immediately increase the number of clients brought into the Job Skills Development Program;following all CDC, Federal and State COVID guidelines. A full restoration will be made to the program allowing for more clients getting necessary Job readiness training in the form of vocational evaluations, individualized employment planning services,work adjustment training,occupational skills,competitive job placement within the community and work transition services. A minimum of twelve additional clients will be served during the fiscal year that would otherwise not have been provided these beneficial services. With the increase in intake clients Brantley Center will be able to pursue and secure more contracts within the community thus allowing for additional revenue. o' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 - Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Brantley Center, Inc Program Name:Job Skills Development Program r 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of clients who received employment rehab services 20 Number of consumers who improved score on the vocational evaluation training report 13 Number of consumers with improved productivity percentages 13 Number of consumers who successfully completed the job-readiness classes 15 Number of consumers placed in competitive employment for a minimum of 90 days 11 Number of students who receive work transition services and were placed in competitive employment 0 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 80,800 105,700 Professional Fees 5,000 8,100 Operations Supplies 4,600 5,000 Equipment 1,000 6,000 Other: Employment Benefits 5,200 7,000 Other: Equipment/Auto Repairs and Maintenance 5,000 5,500 Other: Insurance 4,600 5,600 Other: GE taxes 2,868 3,000 Other: TOTAL 109,068 145,900 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Brantley Center, Inc Program Name:Job Skills Development Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. .All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): Member or members of the Council Dl Staff appointed by a member of the Council The Mayor The Managing Director D The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts.or potential conflicts of interest: Ell If no conflicts exist, check here. D e 0.prdrem I� dor ����. 2 2 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Brantley Center, Inc Program Name:Job Skills Development Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Brantley Center, Inc Program Name:Job Skills Development Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ` i;'I 1-Oh 2021 Signature of Authorized Person Date TrOd \wl D\Ve&k Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Brantley Center, Inc Program Name:Job Skills Development Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients who recieved employment rehab services 25 Number of consumers who improved score on the vocational evaluation training report 10 Number of consumers who susccessfully completed the job readiness classes 15 Number of consumers placed in competitive employment for a minimum of 90 days 5 Number of students who receive work transition services and were placed in competitive employment 4 TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations 12,000 Supplies Equipment Other: Clients Wages 15,000 Other: Equipment/Auto Repairs 3,000 Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Budge House, Inc. Care Coordination 49 COri County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Bridge House, Inc. Program Name:Care Coordination Agency Director: Andi Pawasarat-Losalio Phone No.:(808 )322 —3305 Contact Person: Andi Pawasarat-Losalio Phone No.:(808 )322 —3305 Mailing Address: Address: P.O. Box 2489 Address: • City,s-r,zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687B Mamalahoa Hwy. Address: City,ST,zip Holualoa, HI 96725 Email Address: director.bridgehouse@gmail.com Fax No.: (808 )322 —0809 Accountant/CPA: Carbonaro CPAs & Managgement Group Phone No.:(808 ) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street city,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua ❑© North Kona El South Hilo El North Kohala Q South Kona © North Hilo 0 South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged Victims of Health or Social Crises El Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hatwai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name: Care Coordination 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY-19-20 FY 20-21 so so S® 2.Agency Mission Statement: New Mission Statement: Guided by our values of Pilina(connection),Aloha'Aina(love of the land), Lokahi(unity), Maluhia(peace), and Pono (virtue)we work with the client's best interest at heart to create a supportive environment during the recovery process. Agency origin Mission Statement:The Bridge House mission is to assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe,structured and supportive environment. . 3. Program Description: Care Coordination actively assists and supports clients by providing assistance to access care in the following area: medical, behavioral health educational,social services,financial, insurance,advocacy/legal/judicial, and connections to community resources. This service will be available to any client in any Bridge House program, or person with a substance abuse disorder within the community wanting assistance to enter care for treatment in any program within the community(may be used in conjunction with staff community outreach). Care Coordinators support a client's access to supportive services by working to communicate with the clients,treatment providers,and other community services to help improve positive outcomes for the client.This is a client centered service where the Care Coordinator begins by forming a healing working relationship with the client from the first contact with the intent of following our adopted values(Pilina (connection),Aloha`Aina(love of the land), Lokahi(unity), Maluhia(peace),and Pono(virtue)along with culturally appropriate techniques. Continued coordinated care will last as long as is needed during the client's continuum of care. • Coordination helps with providing referral clarity, is a liaison between care, and is a prevention of information loss. Care Coordination improves client outcomes by managing population health risk, expands access to resources in assisting with navigating complexities. Additionally, during the beginning of the pandemic,we quickly realized that clients who left our housing program were suffering with lack of support in the community. Many social service agencies had either shutdown or had limited services available with easy access.This included probation supervision&drug testing. Many clients during the onset of the pandemic relapsed, reoffended, lost housing and ended up back in jail. Our response to this client crisis was to expand our Care Coordination to have staff meet clients in the community, as well as offer support by phone,or video conf., and assist with linkage to services needed.This included drug testing, providing paperwork, assisting with technology use, scheduling appointments, speaking with service providers to access care,attainment of documents,and help with needed supplies. With this response we have seen a dramatic turnaround in client outcomes. It showed us that the additional support showed positive outcomes by increasing protective factors and decreasing barriers. 4. Total Budget& Position Count: Total Program Budget: $ 25,000.00 . Total Program Position Count: .5 Total Agency Budget: $552,066.00 Total Agency Position Count: 8 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. • Program Name: Care Coordination • 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $ 12,000.00 Grants&Contracts $ 13,000.00 TOTAL: $ 25,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are working on sustainability planning for diversification of income.We continue our on-site agricultural endeavors and sell produce to local vendors.While our agricultural pursuits contribute some income,the current proceeds from these sales are insufficient to support the program.As such,we continue to seek funds from both private and public funders.We also leverage funding by accepting donations of items and accept volunteers from the community. We continue to work on expanding fee for service and billable services which may help to support the housing program. This year we plan to seek specialized accreditation to open billing possibilities for servicing clients in our programs and in the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives for Care Coordination is to improve overall health and wellbeing of men and women suffering from a substance use disorder by reducing readmissions to substance abuse treatment and referrals for residential treatment, reduce emergency medical visits, reduce arrests, increase compliance with judicial system, increase protective factors of client where client feels supported, and improve communication among client's providers. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name: Care Coordination 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) • Approx 40 adult men and women will participate in Care Coordination.of that group 70%will have no new arrests we expect to see improved outcomes of reductions in arrests, relapse,emergency visits& 70%no emergency visits or hospitalizations hospitalizations and increased compliance with legal issues, and reports of clients feeling 80%increased compliance with legal issues supported and that their life and health have improved. 90%report they feel supported and life&health has been improved eo%feel that they con now access services in the community more easily on Meir own . At 6-months post discharge:Clients will 1)Report that the support they received had a direct impact and produced positive outcomes 95%Report coordination resulted in an improved life 2)Can report that they continue to have positive outcomes in the same areas at time of completing services 70%report continued positive outcomes Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $16,480.00 $ 8,000.00 Professional Fees $ 1,200.00 $ 800.00 Operations $ 1,420.00 $ 700.00 Supplies $ 800.00 $ 200.00 . Equipment $ 200.00 $ 100.00 Other: payroll taxes & benefits $ 4,900.00 $ 2,200.00 Other: $ Other: Other: Other: • TOTAL $ 25,000.00 $ 12,000.00 *If applicable • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 . Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Care Coordination 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Walter Welton POSITION: Board President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council 1* Staff appointed by a member of the Council D The Mayor The Managing Director Di The Director of Finance l The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: WI If no conflicts exist, check here. 1 /28/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Care Coordination ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Care Coordination 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 /28/2021 Signature of Authorized Person Date Board President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 s , • County of flawai6 i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Care Coordination 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Approx 40 adult men and women will participate in Care Coordination. of that group 70%will have no new arrests hospitalizations and increased compliance with legal issues, and reports of clients feeling 70%memer9en Yvti,ar hasp e4m4crs supported and that their life and health have improved. watuutemed 90%feel that they can now access smites In the mtmaney nom may on act c nt At 6-months post discharge:Clients will 1)Report that the support they received had a direct Impact and produced positive outcomes and improved life 1) 95% 2)Can report that they continue to have positive outcomes in the same areas at time of completing services 2) 70% TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages $ 8,000.00 Professional Fees $ 800.00 Operations $ 700.00 Supplies $ 200.00 Equipment $ 100.00 Other: paroll taxes & benefits $ 2,200.00 Other: $ Other: Other: Other: TOTAL $ 12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Bridge House, Inc. Clean &Sober Living Program 50 Copt ti County of Hawai`i Nonprofit Grant Application FY2021-22 �P Agency Name: Bridge House, Inc. Program Name:Clean & Sober Living Program Agency Director: Andi Pawasarat-Losalio Phone No.:(808 )322 —3305 Contact Person: Andi Pawasarat-Losalio Phone No.:(808 )938 —8942 Mailing Address: Address: P.O. Box 2489 Address: City,ST,zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687B Mamalahoa Hwy. Address: City,sT,zip Holualoa, HI 96725 Email Address: director.bridgehouse@gmail.com Fax No.: (808 )322 —0809 Accountant/CPA: Carbonaro CPAs & Management Group Phone No.:(808 ) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua [' North Kona ❑■ South Hilo 0 North Kohala Q South Kona Q North Hilo ❑® South Kohala ❑® Ka'u Services or Activities To Be Provided: (One or more can be checked) g Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ©Victims of Health or Social Crises ❑i Needs of the poor 0 Physical/Emotional Disabilities LI Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY19-20 FY20-21 _ _ . _ .. _._ _ 15,.500.00 �~ �,� $15,625.00 $ 2. Agency Mission Statement: • New Mission Statement: Guided by our values of Pilina(connectiori);Aloha'Aina(love of the land), Lokahi(unity), Maluhia(peace),and Pono (virtue)we work with the client's best interest at heart to create a supportive environment during the recovery process. Agency origin Mission Statement:The Bridge House mission is to assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe,structured and supportive environment. • 3. Program Description: Bridge House has always recognized the tremendous need for safe, sober housing and transitional housing. Lack of affordable,supportive housing is an issue on our island,especially in Kona where rental rates are high, &inventory is low. Bridge House's Clean&Sober Living Program is designed to provide opportunities for supportive housing services up to fourteen(14)individuals for up to six(6)months at a time-at our main site. It is estimated that 50 individuals will be served each year of the contract.All referrals for residency are screened using a Universal Standardized Intake Screening Form and are reviewed for eligibility and appropriateness; preference given to pregnant women and intravenous drug users. New clients complete a Sober Living Assessment at the time of intake to assist with the creation of a Health& Wellness Plan.While residing in the housing program clients receive continuum of care services and activities that support client needs.This array of educational and support group services include care coordination,transportation,smoking cessation education, communicable disease education and testing,Vocational Skills Building, access to substance abuse treatment, health&nutrition education, access to community support group meetings, acupuncture, gardening, cultural activities,community service opportunities, assistance with housing applications and planning for future housing as well as other care coordination support services. Staff makes referrals to external services for clients in need of additional supports. Each client is assisted to develop and maintain a healthy support system that fosters a positive transition back into the family and community. Bridge House is well connected to support services in our island community as it ha been serving the community for 30 years. Homeless housing in Kona has limited availability, a majority of spaces uses the Housing First model where drugs and alcohol use does not exclude participation,this is not a recovery model and therefore it is often inappropriate for a person in early recovery; putting them at greater risk for relapse. Bridge House is a recovery model and is better prepared to serve those wanting to maintain sobriety. In Kona,besides Bridge House,there are 4 sober housing programs and they all have barriers for access to housing.These limits are 1)need for specific health insurance(HMSA/HMSA Quest only)2) has income/payment requirements 3)only serve justice involved individuals.This makes Bridge House the only Sober Living Program in Kona without such barriers.We fill a gap and need in the community. 4. Total Budget& Position Count: Total Program Budget: $297,000.00 Total Program Position Count: 4 Total Agency Budget: $552,066.00 Total Agency Position Count: 8 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai'i $ 25,000.00 Program Fees • $ 30,000.00 Grants&Contracts $ 218,000.00 Agricultural Income $ 5,000.00 Other emergency or Covid-19 related Grants • $ 19,000.00 • TOTAL: $297,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are working on sustainability planning for diversification of income.We continue our on-site agricultural endeavors and sell produce to local vendors.While our agricultural pursuits contribute some income,the current proceeds from these sales are insufficient to support the program.As such,we continue to seek funds from both private and public funders and have received assistance in this area.We also leverage funding by accepting donations of items and accept volunteers from the community. We continue to work on expanding fee for service and billable services which may help to support the housing program. This year we have started the credentialing process of specialized accreditation to open billing possibilities for servicing clients in our programs and in the community. • • 7. Program Objectives Using County Nonprofit Grant Program Funds: From its inception, Bridge House has recognized the tremendous community need for transitional housing for the recovery community as they often move from a highly structured setting towards successful independent living. Bridge House is designed to provide clean&sober housing spaces for up to fourteen.(14)individuals at any given day. The focus of the Clean&Sober Program is to provide the necessary support and encouragement to assist clients to adjust to a chemically abstinent lifestyle. Most of our clients come to us unemployed and homeless or from unsafe living environments.We provide services to enhance independent living skills that foster the transition to independent housing, self-management,and to give support to clients as they rejoin their communities and families as healthy productive people. We do this by providing a six-month stay in a schedule driven and values-oriented environment. Other supports such as case management/care coordination provide oversight to assist with ensuring appropriate support services are in place for each client. When a client completes the program he/she will have gained enough support through the program to be either employed or participating in an education program, have safe, stable,sober housing, have a support network, have supports in place for mental health(if needed), have been connected with medical care, be able to keep a schedule and a budget, have a deeper understanding of what it means to be self-supportive,will have a clear idea of what it takes to live a clean&sober life and the supports they need to have in place to make it successful. Clients will also have gained respect for the'aina and understand the importance of helping others as an island community member. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai6l.Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 8. TABLE I: : What are the measurable performance outcomes-that would be achieved with this funding? PROGRAM PERFORMANCE.OUTCOMES - (i.e.:How are youmeasuring what happens for the Participants after they have participated in your, program?Describe,be specific.) Approx. 50 adult men &women will be served; and d of those completing the program: 90%will be employed or in a school/training program;90%will attain legal documents/ID At 6-months post-discharge:Clients who have completed the program will be employed and/or 70%of graduates will make these marks participating in school/traning program; report no new arrests; report no relapse; at 6-month follow-up maintain safe sober housing Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $112,600.00 $112,600.00 $ 10,000.00 Professional Fees $ 8,400.00 $ 8,400.00 $ 500.00 Operations $142,600.00 $140,345.00 $ 10,700.00 Supplies $ 9,100.00 $ 9,100.00 $ 800.00 Equipment Other: payroll tax & benefits $ 24,055.00 $ 24,055.00 $ 2,400.00 Other: staff training $ 2,500.00 $ 2,500.00 $ 600.00 Other: Other: Other: . TOTAL $299,255.00 $297,000.00 $ 25,000.00 *If applicable EXHIBIT A - NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Clean & Sober Living Program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of-interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Walter Welton POSITION: Board President . May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): (l Member or members of the Council 11 Staff appointed by a member of the Council The Mayor E] The Managing Director The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. -`' , 1 /28/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Clean & Sober Living Program 11. Certification of Understanding (Pagel of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property; or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Clean & Sober Living Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence}must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 /28/2021 Signature of Authorized Person Date Board President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii'i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. • Program Name:Clean & Sober Living Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Approx.50 adult men &women will be served; and of those completing the program: 9096 boll be employed or In a adroolnranng program;90%.11 aCam lapel docmaeMeilD At 6-months post-discharge:Clients who have completed the program will be employed and/or participating in school/traning program; report no new arrests; report no relapse; 7D°6 of gtadua es will make Nese ma maintain safe sober housing at 6-month follow-up TABLE II: FY 21-22 Council PROGRAM EXPENDITURES • Grant Request Award Salary and Wages • $ 10,000.00 Professional Fees $ 500.00 Operations • $ 10,700.00 Supplies $ 800.00 Equipment Other: payroll tax & benefits $ 2,400.00 Other: staff training $ 600.00 Other: Other: . Other: ' TOTAL $ 25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Bride House, Inc. Vocational Skills Building Program 51 Cor4 County of FIawai`i .Nonprofgt Grant Application FY2021-22 Agency Name:Bridge House, Inc. Program Name:Vocational Skills Building Program Agency Director: Andi Pawasarat-Losalio Phone No.:(808 )322 —3305 Contact Person: Andi Pawasarat-Losalio Phone No.:(808 )322 —3305 Mailing Address: Address: P.O. Box 2489 Address: City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687B Mamalahoa Hwy. Address: City,ST,Zip Holualoa, HI 96725 Email Address: director.bridgehouse@gmail.com Fax No.: (808 )322 —0809 Accountant/CPA: Carbonaro CPAs & Managgement Group Phone No.:(808 ) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE T,• KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES . ... ......._..._.__. Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Q Hamakua Q North Kona Q South Hilo Q North Kohala Q South Kona El North Hilo 0 South''Kohala ' Q Ka`u . ........ . .... . Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns fl Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged 0 Victims of Health or Social Crises Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-,2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22. Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 " FY119-20 FY 20-21 $11 ,300.00 $ 13,325.00 $11 ,625.00 2. Agency Mission Statement: New Mission Statement: • Guided by our values of Pilina(connection),Aloha Aina(love of the land), Lokahi(unity), Maluhia(peace),and Pono (virtue)we work with the client's best interest at heart to create a supportive environment during the recovery process. Agency origin Mission Statement:The Bridge House mission is to assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe, structured and supportive environment. 3. Program Description: Ongoing research consistently confirms that employment is a strong correlate with successful recovery from addiction along with re-establishing connections to family and the community.As a result of their substance abuse, approximately 90%of all our new admits are unemployed/unemployable upon arrival to Bridge House.The Vocational Skills Building Program(VSB) provides a highly structured opportunity for our clients to prepare for employment, re-connect with lost values&create new ones. Participation in bur VSB program is mandatory for all clients of our clean&sober housing program.All new clients complete a vocational skills questionnaire.The results of this evaluation, along with personal observation by staff, identification of needed skills, along with attitudes and behaviors help to identify areas of need.The VSB program is supported through culturally relevant programming as well as the inclusion of a culturally based financial literacy/education program. The VSB program provides highly structured on-site job training and off-site supervised community volunteer experiences.All clients are evaluated on performance of job assignments as an individual and as a group. Clients are given support for improvement. Staff also assists with resume preparation, provides training in the use of basic office equipment and basic computer skills, may conduct mock:interviews,-training on use and care of tools,facilitates linkages • to other community resources for enhancement of work skills as well as educational opportunities and offers guidance to jobs appropriate to ability. The very close working relationship between VSB staff and our clients provides for ample opportunities to address/remediate unhealthy thinking and behaviors that-have become core parts of the substance abusing lifestyle. Clients in the VSB program are continually being challenged to address and change their dysfunctional core values in the areas of respect, responsibility,trust and reliability. Care coordination services are provided to assist in navigating the process of attaining legal documentation for employment(i.e.:state ID,social security cards,birth certificates...). Many of our clients have never had, or have lost,their legal identification and most often do not have the financial resources to obtain or replace them.The lack of identification can be a major barrier to attaining legal employment.Transportation is also provided to obtain job applications, attend interviews and attain legal documents and identification. 4. Total Budget&Position Count: Total Program Budget: $101 ,700.00 Total Program Position Count: 1.5 Total Agency Budget: $552,066.00 Total Agency Position Count: $ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai'i $ 20,000.00 Hawai'i Island United Way • $ 16,500.00 Program Fees $ 9,500.00 Contributions $ 2,800.00 Grant&Contracts $ 49,500.00 Agricultural Income $ 3,400.00 TOTAL: $101,700.00 Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: We are working on sustainability planning for diversification of income.We continue our on-site agricultural endeavors and sell produce to local vendors.While our agricultural pursuits contribute some income,the current proceeds from these sales are insufficient to support the program.As such,we continue to seek funds from both private and public funders.We also leverage funding by accepting donations of items and accept volunteers from the community. We continue to work on expanding fee for service and billable services which may help to support the housing program. This year we plan to seek specialized accreditation to open billing possibilities for servicing clients in our programs and in the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The VSB program's primary objective is to prepare clients to enter/re-enter the workforce and maintain values that promote a clean and sober lifestyle.As a result of their addiction most individuals have disengaged from mainstream society(e.g.: loss of values, abandoning family, losing employment, engaging in criminal activity).The substance abuser no longer shares many of the healthy benefits/values that are found within the community. Maintaining employment has consistently been identified as one of the primary components that facilitates successful recovery as well as reconnection with family and community. Every individual that secures employment and begins the process of re-engagement is likely to eliminate self-destructive behaviors, rejoin their family,experience enhanced health, and begin to'give back'to the community.We expect all graduates to have secured employment prior to leaving Bridge House and to report still being employed at 6 months post-discharge. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Vocational Skills Building Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Approx.50 adult men and women will beserved and of those completing the program: 90%will be employed or in a school/training program; 90%will attain legal documents/ID At 6-months post discharge: Clients who completed the program will be employed and/or 75% of graduates will make these participating in a school/training program; report no new arrests; report no relapse - marks at 6-month follow-up Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES, Actual* Total Budget Grant Req Salary and Wages $48,000.00 $48,000.00 $ 11,200.00 Professional Fees $ 9,800.00 $ 7,780.00 $ 800.00 • Operations $23,800.00 $ 22,800.00 $ 5,000.00 Supplies $ 9,800.00 $ 8,600.00 $ 1,200.00 Equipment $ 2,000.00 $ 2,000.00 $ 800.00 Other: fringe benefits $ 8,200.00 $ 8,200.00 $ 400.00 Other: payroll taxes $ 4,320.00 $ 4,320.00 $ 600.00 Other: Other: Other: TOTAL $105,920.00 $101,700.00 $ 20,000.00 • *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Vocational Skills Building Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Walter Welton POSITION: Board President May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): (Ul Member or members of the Council ® Staff appointed by a member of the Council O The Mayor O The Managing Director O The Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. ! = 4re-Saa7-(71 /28/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of flawai'i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Vocational Skills Building Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we)understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Vocational Skills Building Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s): I (we) understand that failure to submit thefinal report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. °I /2 8/2021 Signature of Authorized Person Date Board President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021'-2022 Page 7 of 8 County of flawai6 i Nonprofit Grant Application FY2021-22 Agency Name: Bridge House, Inc. Program Name:Vocational Skills Building Program 12, COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Approx.50 adult men and women will be served and of those completing the program: 90%will be employed or in a school/training program; 90%will attain legal documents/ID At 6-months post discharge: Clients who completed the program will be employed and/or 75%of graduates yell make these participating in a school/training program; report no new arrests; report no relapse marks at 6-month follow-up TABLE H: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $ 11,200.00 Professional Fees $ 800.00 Operations $ 5,000.00 Supplies $ 1,200.00 Equipment $ 800.00 Other: fringe benefits $ 400.00 Other: payroll taxes $ 600.00 Other: Other: Other: TOTAL $ 20,000.00, Additional Council directives regarding award: EXHIBIT NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Center for Getting Things Started Ono-licious Youth Cooking Contest- Local Food Promotion 52 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Center for Getting Things Started Program Name:Ono-licious Youth Cooking Contest - Local Food Promotion Agency Director: Koh Ming Wei Phone No.:(808 ) 443 —9231 Contact Person: Koh Ming Wei Phone No.:(808 ) 443 —9231 Mailing Address: Address: 12-7106 Puna Kai St. Address: City,ST,Zip Pahoa HI 96778 Facility Address: Address: as above Address: City,ST,Zip Email Address: mingwei@c4gts.org Fax No.: ( ) — Accountant/CPA: Gregory Paul Wilber Phone No.:(808) 765 —8679 Firm (if applicable): Mailing Address: Address: 12-7106 Puna Kai St. City,ST,Zip Pahoa HI 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna 0 Hamakua Q North Kona Q South Hilo 0 North Kohala 0 South Kona O North Hilo Q South Kohala 111 Ka`u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns 0 Youth ❑Victims of Crimes Q Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program Name: Ono-licious Youth Cooking Contest - Local Food Promotion 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 n/a n/a n/a 2.Agency Mission Statement: Our Mission- Initiate regenerative economy through fostering climate-cooling culture. Our Vision-We envision a regenerative culture that supports human activities in harmonious relation with the living earth. Center for Getting Things Started(C4GTS)founded in 2017, provides access to sustainability education design and development.C4GTS works with students,teachers, organizations, and communities to incorporate and live an ethic of sustainability in practice. Education for Sustainability(EfS) is defined as a transformative learning process that equips students,teachers, and school and community systems with the new knowledge and ways of thinking we need to achieve economic prosperity and responsible citizenship while restoring the health of the living systems upon which our lives depend. 3. Program Description: Ono-licious Youth Cooking Contest promotes local food consumption and culinary creativity among the youth of Hawaii County. In 2020-2021,C4GTS conducted a county-wide virtual Youth Cooking Contest supported by Hawaii County R&D. Hawaii County R&D Food Access coordinator,two CTE teachers,two FoodCorps Service members, and two High School youth were part of the judging rubric creation, ensuring input from a wide range of expertise. From the 30 applicants for three categories-Grades 5-8, High School and USDA School Meal, 18 semi-finalists were selected.The semifinalists were provided KTA gift cards to purchase the local ingredients needed for their recipes.They were also provided a microphone and a tripod to support the video creation. Providing these supplies ensured that youth from all income levels could participate which is crucial. Supplies take up most of the budget. Of the 18, 14 turned in their videos and local food recipes, and 6 advanced to the finals. Local chefs, school cafeteria managers, and a top youth culinary student were the judges.The live virtual finals was held on January 23, 11 am-12 noon, and more than 125 people"zoomed"in to vote for the top young chef, including teachers,fellow students, community members, and even supporters from the mainland.The 14 semifinalists recipe videos are posted on the HIFA (Hawaii Island Food Alliance YouTube)and accessible via the HIFA website. C4GTS proposes to make this an annual event, working with more and more DOE,charter, and private school culinary arts teachers,to integrate the contest into the school calendar,very much like Science Fair.Teachers can guide and support their students to enter at the County-level,The County winners will choose to proceed to the State level.The elite State-level competition is organized and supported by HAF-Hawaii Agriculture Foundation.Science students have the Science Fair to urge them into higher performance outputs,the Ono-licious Youth Cooking Contest proposes to do the same for the Culinary Arts. Conducting a video/virtual contest decreases the expenses and logistics, supporting wide participation even during times 4.Total Budget & Position Count: Total Program Budget: 23,300 Total Program Position Count: 0.2 FTE Total Agency Budget: 155,000 Total Agency Position Count: 1.5 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program Name: Ono-licious Youth Cooking Contest'- Local Food Promotion 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Hawaii Agriculture Foundation-advertising,promotion-in kind 2,000 KTA-10%discount for produce,featuring recipes in coupon books,website 1,000 TOTAL: 3,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will be seeking in-kind support from places such as KTA. In 2020-21, KTA provided a 10%discount on prizes for the semifinalists. We will ask if KTA can continue providing the 10%discount on the prizes and in 2021-22 feature the the winning recipes on KTA's monthly coupon book and on their website. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Promotional of locally grown, harvested or caught food. 2. Food Systems education-the role of culinary arts in local food security and consumption. 3.Social-emotional wellness-supporting children whose interests are in the culinary arts to succeed and achieve in this field. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program Name: Ono-licious Youth Cooking Contest - Local Food Promotion 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) County wide participation in general application 80 youth Semi-finalists 40 youth Finalists 6 youth+12 youth(4 teams of 3 for team category) Healthy local food recipes created and shared 30 recipes Youth with more knowledge of local food systems 50%of participants Youth who state interests in pursuing food systems related education or career 25%of participants Webinars on cooking and preparing local food 3 webinars with 75 attendees each Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 3,500 6,000 6,000 Professional Fees 250 1,000 0 Operations 250 1,000 1,000 Supplies 6,300 8,500 8,500 Equipment Other: Honorariums for judges 1,050 2,000 2,000 Other: Prizes for finalists 1,350 1,800 1,800 Other: High School Culinary Arts Consultant and support fi 3,000 3,000 Other: Other: TOTAL 12,700 23,300 22,300 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program Name: Ono-licious Youth Cooking Contest - Local Food Promotion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Koh Ming Wei POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 0, 12.6 fuzJt, Ji Signatur, . � thor' • •= y title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program.Name: Ono-licious Youth Cooking Contest - Local Food Promotion , 11. Certification of Understanding (Page 1 of 2) If: I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurateprior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, usingthe templateprovided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 Countyof Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program Name: Ono-licious Youth Cooking Contest - Local Food Promotion 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any paMent s . I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. IliiI • 111111t17/61�z( Signatu �• • jilt • i erson Date V�1 4,..e Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Center for Getting Things Started Program Name: Ono-licious Youth Cooking Contest - Local Food Promotion 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Child & Family Service East Hiawai`i Alternatives to Violence 53 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence Agency Director: Karen Tan Phone No.:(808 ) 681 –3500 Contact Person: Joey Keahiolalo Phone No.:(808 )681 -3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,zip Ewa Beach, HI 96706 Facility Address: Address: 1045 A Kileauea Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: " (808 ) 681 -5280 Accountant/CPA: CW Associates, CPAs Phone No.:(808) 531 -1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Suite 1040 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) IN( Puna 1 Hamalcua n North Kona PI South Hilo North Kohala n South Kona n North Hilo n South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) I•I Educational concerns [■{Youth n Victims of Crimes Culture and the arts • Aged I■I Victims of Health or Social Crises n Needs of the poor — Physical/Emotional Disabilities III! Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $14,375(Island)$7,187.50(East Hawaii) $10,825(Island)$5,412.50(East Hawaii) $9,375 2. Agency Mission Statement: The Alternatives to Violence(ATV) Program fits perfectly with Child&Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii,ATV program services have been pro4ided for more than seven years.CFS offers nearly 50 programs statewide with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.The broad spectrum of services provided by CFS include domestic violence intervention, case management,therapeutic foster care, alternative education for alienated youth, prevention and treatment of child abuse, recovery and prevention of substance abuse, and school and community- based counseling services for children and their families. Infants, children, adolescents,young adults, individuals and • 3. Program Description: Funding in the amount of$35,000 is being requested to support staffing for our Alternative's to Violence Program(ATV). This includes a 16 hour per week Domestic Violence Specialist II that would provide vital direct services to victims of domestic violence to help them enhance their safety through assistance with obtaining Temporary Restraining Orders (TRO's), Court Advocacy, Safety Planning and linkages to community resources; and support, intervention, education and case management to individuals who batter to help them to break the cycle of their violent behaviors and to prevent further domestic violence. Funding would also help to support a very small portion of the following positions: Program Director I, Program Secretary,Administrative Services Manager and Director of East Hawaii Programs.These positions provide administrative oversight and support to the ATV contract. In addition to supporting staffing,the funding requested would help to support a small percentage of the overall program administrative and operational costs. About the Alternatives to Violence(ATV) Program: The Alternatives to Violence Program (ATV)offers an array of services for individuals who are victims of domestic violence and their children,youth who are aggressive and or engage in bullying, abusive behavior, and for men and women who abuse.The services provided to victims include assistance with obtaining Temporary Restraining Orders (TROs), safety planning, court advocacy and support groups. (Continued on Attachment) 4.Total Budget& Position Count: Total Program Budget: $364,300 Total Program Position Count: 5.25 FTE Total Agency Budget: $6,630,056 Total Agency Position Count: 87 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of I Iawai`i Nonprofit Grant Application F 2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(Funding requested in this proposal) $35,000 Judiciary $223,014 HIUW $2,850 Program Fees $3,000 TOTAL: $263,864 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS works hard to maintain,diversify and increase funding for all our program services. Given the number of individuals and families impacted by domestic violence on the Big Island,domestic violence is a pressing public health and social welfare issue for our community. In FY 2019, CFS applied for and was re-awarded a contract with the Judiciary which is the primary funding source for the ATV program. Most recently, in FY 2020, CFS was awarded VOCA funding to support the victim services component of the ATV program. CFS has a grants management department which actively researches new funding opportunities. CFS has been challenged to maintain funding for the ATV program. In fiscal year 2020, CFS lost an additional$65,000 in Judiciary funding which was vital to support the victim services portion of the AN program. Recently, as a result of Judiciary funding cuts,the CFS AN Program was cut by 20%effective September 1, 2020.This again impacted the Victim Services portion of our contract and resulted in a reduction in funding for TRO and Court Advocacy Services.We had to reduce both administrative and direct service staff. Fortunately,we were able to utilize funding from another contract to support the FTE lost with the Judiciary contract cuts.Without support from other contracts, CFS would see a reduction in TRO services and would have to eliminate Court Advocacy services. (Continued on attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: Goal/expected Outcome for Individuals who batter:To change destructive behaviors and replace them with positive healthy behaviors. • Performance Measure: 80%of participants will successfully complete the curriculum(Batterer Intervention-SAFE curriculum). Performance Measure:90%of participants who attend batterer intervention services will self-report that service has made a positive impact on their lives. (Continued on Attachment) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) #of individuals assisted with completing a TRO application 350 #of batterers who received domestic violence intervention 30 #of court assistance services provided 500 %of participants who complete the curriculum(Batterer intervention-SAFE curriculum 80% %of participants who attend batterer intervention services who self-report that service has 90% made a positive impact on their lives (Continued on Attachment) Attach additional pages as necessary. 9.TABLE II: FY PROGRAM EXPENDITURES 20 21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $259,821 $260,000 $26,065 Professional Fees $149 $150 Operations $71,353 $71,350 $6,635 Supplies $6,622 $6,600 $500 Equipment Other: Participant Assistance-Trauma Support/Sustenanjj $1,100 $1,200 $500 Other: Rent and Utilities $24,605 $25,000 $1,300 Other: Other: Other: TOTAL $363,650 $364,300 $35,000 *11 applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council Il Staff appointed by a member of the Council O The Mayor QI The Managing Director DI The Director of Finance • The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: FO If no conflicts exist, check here. 1/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 of '`^ � �� ��-��� � �� County ��=,,^� � �"�^����^� `�^^ ^� ���� ���^wxx ^ � �n��^-��~ Child & Family Service �� Name: ^` 8D�� Agency Program Name: East Hawaii Alternativs to Violence 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representativeor expendirsihtagenc«)fuU,free, ondunrestrictedacceSsandauthoritv to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii' Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. |favvardedagrantfronntheCountyofHavvai1' | (vxe) understondandvvi|| connp|yvviththerequirennent to enroll with Hawaili Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawail, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hannai"i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, us/n4 the template providedwill impact the evaluation of your prograeS or agency's future funding requests. EXH8ITA NONPROFIT GRANT APPLICATION 1-1'2021 2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. p‘titioti) 1 /29/2021 Signature of Authorized Person Date Chief Performance Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 • Child & Family Service Agency Name: Program Name: East Hawaii Alternatives to Violence 12. COUNCIL AWARD KSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result # of individuals assisted with completing a TRO application 350 # of batterers who received domestic violence intervention 30 # of court assistance services provided 500 % of batterers who complete the curriculum 80% % of batterers who report service made a positive impact on their life 90% (Continued on Attachment) TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $26,065 Professional Fees Operations $6,635 Supplies $500 Equipment Other: Participant Assistance $500 Other: Rent& Utilities $1,300 Other: Other: Other: TOTAL $35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 • • Attachment Applicant: Child & Family Service Program: East Hawaii Alternatives to Violence 3. Program Description (Continued) Seeking services through the ATV program, is often the first step that victims take toward enhancing their own safety. They often come to the CFS ATV program to get assistance with obtaining a TRO. In the process of helping victims to apply for a TRO, staff talk with victims about how to plan for their safety and inform them of the Domestic Abuse Shelter Services. Applying for a TRO for the first time can be a very emotional, overwhelming and scary experience for victims. Having a staff to walk them through the process, listen to their story and take the time needed to provide them with vital safety information and options, helps victims make the necessary preparations to enhance their safety as well as the safety of their children. The ATV program also provides Court Advocacy to victims who need to go to court for.a TRO hearing. Program staff do not give legal advice but they do provide information about the court process and sit with the participant to provide support. Having to face one's abuser is often a very emotional and scary experience for the victim. Having ATV program advocates at their side lets the victim know that they are not alone and helps to create a greater sense of safety and support. In addition to helping victims to enhance their safety, it is essential to also educate and support batterers to break the cycle of their violence. The ATV program provides domestic violence intervention classes to both men and women who batter. The goal for our program participants is to recognize that domestic violence in intimate relationships generates disrespect and harm that are inconsistent with the values, beliefs, and conduct of every culture. The goal of the ATV program is to end domestic violence through providing services, partnering with community resources, and participating in community education about domestic violence, thereby creating a tipping point in our community awareness that healing from trauma is an imperative, and we cannot tolerate domestic violence. To end the cycle of domestic violence and help families to fully heal, it is critical that those who perpetrate the violence receive comprehensive treatment to include group education and intervention, case management and counseling. In many cases, perpetrators of domestic violence were themselves victims at one time or another in their lives and domestic violence is deeply entrenched within their childhood upbringing and is what they know to cope with stressors. Supporting offenders in their development of alternative coping strategies, is a primary goal of the ATV Domestic Violence Intervention Program. The ATV program closely adheres to the Hawaii Batterers Standards, to include providing 26 weeks of intensive group intervention that focuses on holding the batterer accountable for their behavior, educating participants about the different forms of domestic violence, increasing participant's awareness of their own thought patterns and triggers for abuse, helping participants to understand the relationship between thought and behavior using cognitive behavioral therapeutic methods and motivational interviewing, providing hands-on strategies for changing unhelpful thoughts and or interrupting learned responses of reacting immediately and in abusive ways, i.e. choosing to take a cool down rather than responding right away and facilitating opportunities for social support with other group participants who understand what it is like to struggle with domestic violence. All CFS Hawaii Island ATV program sites utilize the Stop Abuse for Everyone (SAFE) curriculum for the men's Domestic Violence Intervention (DVI) program. This is a curriculum that incorporates evidence-based components including motivational interviewing, cognitive behavior therapy and the change theory into our work with offenders. There are separate DVI groups for women and adolescents. Page 1 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Alternatives to Violence All CFS ATV program services are provided through the lens of trauma-informed care. We follow the Risking Connection®model which was developed by the Sidran Institute, to work with individuals and families who have experienced trauma. This model provides a foundation for all the work we do with families and emphasizes the RICH®relationship approach where we offer "Respect, Information Sharing, Connection, and Hope" to everyone we engage within services. In alignment with evidence-based practices and a trauma-informed care framework, staff operate with the understanding that: • Traumatic events such as abuse can cause overwhelming feelings of horror, terror, and hopelessness; • Caregivers with histories of trauma may avoid experiencing their own emotions, which impacts and hinders their ability to respond appropriately to their child's emotional state and needs; • Traumatic stress occurs when exposure to traumatic events overwhelm the individual's ability to cope; • A strong relationship with a trusted caregiver is a potential buffer against traumatic stress for children; • Positive attachment and connections are essential for healthy child and adolescent development; and • Working with families that have experienced abuse and trauma impacts staff, who may also need to be supported and nurtured. ATV program participants are encouraged to access services and resources that can help them to break the cycle of violence and move forward to lead safer, healthier lives. CFS hopes that by offering ATV-services that individuals will receive the support needed to break the cycle of violence in their lives and achieve greater health and well-being. The following is a summary of some of the outcomes the program achieved in FY 2020 PROGRAM PERFORMANCE OUTCOMES Target Achieved # of individuals assisted with completing a TRO 350 495 # of Batterers who received domestic violence intervention 30 36 # of court assistance services provided 500 785 % of batterers who complete the curriculum 80% 64% % of batterers who self-report that services made a positive impact 90% 100% on their life % of victims who report they have a better understanding of the 70% 100% TRO process after receiving ATV services % of victims who have been connected to at least one community 70% 98% resource % of victims who self-report that they have the tools needed to 90% 97% create a safety plan. Page 2 of 5 • Attachment Applicant: Child & Family Service Program: East Hawaii Alternatives to Violence 6. Explain what plans your agency or program has to increase revenues to support this program (Continued) With the support of VOCA funding, we will be able to sustain the TRO and Court Advocacy services through 6/30/2021 at which time the contract will end. CFS plans to reapply for funding but there is no guarantee that we will receive it again for FY 2022. In order to address the decrease in funding for the Victim Services component of the ATV program, CFS will re-apply for VOCA funding. We will also continue to apply for funding through the County of Hawaii, Hawaii Island United Way (HIUW), and actively engage in fundraising efforts. CFS has a Grants Management Department that continuously researches new funding opportunities. CFS does collect a group fee of$300 for our Domestic Violence Intervention program. This covers all 26 groups, a workbook and a certificate of completion. (This fee can be waived and replaced with work exchange for indigent or unemployed program participants.) CFS maintains high accountability to the participants we serve, the community and to our funders. CFS uses Results-Based Accountability (RBA)TM, a decision-making framework, to demonstrate that we are making an impact in the lives of the individuals and families we serve. RBA follows a simple, commonsense process, builds collaboration and consensus, and uses data and transparency to ensure accountability. RBA asks 3 questions: How much did we do? How well did we do it? and Is anyone better off? Positive participant outcomes lead to better community health, safety, well-being and productivity. RBATM is a rigorous and dynamic process that requires a willingness for our organization to really look at the truth of how we are performing and the impact of our services. CFS believes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS is committed to remaining a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will attract additional funding resources. 7. Program Objectives Using County Nonprofit Grant Program Funds (Continued) In order to successfully complete the Domestic Violence Intervention program/curriculum, offenders need to be able to demonstrate the following: • Accountability for abusive behavior • An increase in empathy • The effective use of skills and tools for the prevention of abusive behavior • A completed Relapse and Prevention Plan which identifies possible triggers for abusive behavior, outlines action steps for the prevention of abusive behaviors, and identifies concrete supports. Page 3 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Alternatives to Violence The ATV program will provide the following activities to help batters recognize and change their destructive behaviors: • Hold batterers accountable for their abusive behaviors • Facilitate Domestic Violence intervention groups where batterers receive education about domestic violence, gain an understanding that domestic violence is not acceptable and learn positive tools to cope when experiencing challenges and frustrations • Assist batterers with completing a relapse prevention plan • Provide case management to connect batterers to concrete support Goal/Outcome for victims of domestic violence: To enhance their safety and prevent domestic violence. Performance Measure: 70% of victims who receive ATV services will be connected to at least one community resource. Performance Measure: 80% of victims who receive ATV assistance to complete a TRO will report that they have a better understanding regarding the process for obtaining a TRO Performance Measure: 80% of victims will self-report that they have the tools needed to create a safety plan. The ATV program will provide the following activities to help victims to increase their safety and to prevent domestic violence: • Inform victims about the 24-hour Domestic Abuse Shelter and provide them with the hotline number. • Assist victims with calling the 24-hour shelter hotline number as needed. • Provide victims with a pamphlet on the steps to completing a safety plan and the things to consider. Assist victims with creating a safety plan. • Explain the process for completing a TRO and walk the victim through completing the TRO step-by-step. • Accompany victims at court for their TRO hearing. Provide information regarding the court process and sit with the victim for support. 8. Program Performance Measures (Continued) 8. Table I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Continued from Application) % of victims who report they have a better understanding of the TRO 70% process after receiving ATV services % of victims who have been connected to at least one community resource 70% % of victims who self-report that they have the tools needed to create a 90% safety plan. Page 4 of 5 • Attachment Applicant: Child & Family Service Program: East Hawaii Alternatives to Violence 12. Council Award Worksheet (Continued) Table 1: PROGRAM PERFORMANCE OUTCOMES (Continued from Application) % of victims who report they have a better understanding of the TRO 70% process after receiving ATV services % of victims who have been connected to at least one community resource 70% % of victims who self-report that they have the tools needed to create a 90% safety plan. Page 5 of 5 Chord & Family Service East Hawaii Domestic Abuse Shelter 54 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter Agency Director: Karen Tan Phone No.:(808 ) 681 —3500 Contact Person: Joey Keahiolalo Phone No.:(808 )681 —3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: Ewa Beach, HI 96706 City,ST,Zip Facility Address: Address: 1045 A Kilauea Avenue • Address: City,ST,Zip Hilo, HI 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 -5280 Accountant/CPA: CW Associates, CPAs Phone No.:(808) 531 -1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Suite 1040 • City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO I(EEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program,Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) 1■1 Puna I■1 Hamakua ■I North Kona 1111 South Hilo • North Kohala [:1 South Kona IN I North Hilo ]South Kohala f Ka`u Services or Activities To Be Provided: (One or more can be checked) Is 1 Educational concerns • Youth • Victims of Crimes P Culture and the arts 1■I Aged 1■I Victims of Health or Social Crises (� Needs of the poor I I Physical/Emotional Disabilities IN Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of:Hawai`i Nonprofit Grant Application F 2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,300 $9,075 $10,125 2.Agency Mission Statement: The Domestic Abuse Shelter Program (DAS)fits perfectly with Child&Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children". CFS offers nearly 50 programs statewide with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.The broad spectrum of services provided by CFS include domestic violence intervention, case management,therapeutic foster care, alternative education for alienated youth,prevention and treatment of child abuse, recovery and prevention of substance abuse, and school and community-based counseling services for children and their families. Infants,children, adolescents, young 3. Program Description: Funding in the amount of$30,000 is being requested to support staffing for our Domestic Abuse Shelter(DAS).This includes a 20 hour per week Domestic Violence Specialist II (DVS II)that would provide direct support services to survivors of domestic violence. CFS'primary funding source, DHS, covers the basic operations of the shelter but does not cover the vital support services that are needed to help survivors re-build their lives.The DVS II provides the following support services to survivors: Comprehensive Assessment, Service Planning, Safety Planning, Linkages to community resources, 4. Total Budget& Position Count: Total Program Budget: $547,650 Total Program Position Count: 7.75 FTE Total Agency Budget: $6,630,056 Total Agency Position Count: 87 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(Funding requested in this proposal) $30,000 Department of Human Services $345,250 Department of Human Services-FVPSA Cares Act $3,875 HIUW $6,930 Department of Human Services BESSD HPO Emergency Shelter Grant $20,000 Attorney Generals Office-VAWA $75,000 TOTAL: $481,055 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The funding received from our primary shelter contract is not enough to cover all the costs of operating a 24-Seven Shelter and to provide the support services necessary to help survivors to begin to re-build their lives and to move toward greater safety. CFS relies on braided funding from multiple contracts to support our shelter program. In December of 2020,we re- applied for OHS funding,the primary funding source for our shelter, and were re-awarded the contract. During fiscal year 2021,we also re-applied for VAWA funds and were re-awarded.Additionally,we applied for and received funding from Hawaii Island United Way and the County of Hawaii. Even though,we were fortunate to receive multiple awards from various funders,we are still not able to optimally staff our shelter and program participants are not always able to receive 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the Domestic Abuse Shelter is to provide a safe place where survivors of domestic violence can heal from the trauma they experienced. Specific outcomes of the program are that Survivors will leave the shelter for a safe and secure EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter S. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) #of Survivors who create a safety plan 100 #of adult Survivors served 120 #of Children Served 80 #of Bed Days Provided 7,750 (Continued on Attachment) Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $317,858 $341,570 $23,713 Professional Fees $140 $150 Operations $115,400 $115,450 $4,962 Supplies $11,272 $11,300 $300 Equipment Other: Participant Assistance - Emergency Shelter needs $13,062 $13,000 $200 Other: Food for Shelter Participants $14,897 $15,000 $300 Other: Rent and Utilities $50,577 $51,180 $525 Other: Other: TOTAL $523,206 $547,650 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ▪ Member or members of the Council • Staff appointed by a member of the Council ® The Mayor Ell The Managing Director II The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. atitze; aticto_ 1 /29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/29/2021 Signature of Authorized Person Date Chief Performance Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: East Hawaii Domestic Abuse Shelter KOK +KvmKie.K4K K Kd K.LeKNaV‘a+KK/FPI .rma, +KA W.11.14, , KKK., MK. $rKKAKK KW*,+4..as am* 4e. w on.” 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result # of Survivors who create a safety plan 100 # of adult Survivors Served 120 # of Children Served 80 #of Bed Days Provided 7,750 (Continued on Attachment) TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $23,713 Professional Fees Operations $4,962 Supplies $300 Equipment Other: Participant Assistance $200 Other: Food for Participants $300 Other: Rent & Utilities $525 Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 3. Program Description (Continued) CFS's East Hawaii Domestic Abuse Shelter (EHDAS/Hale `Ghana) and West Hawaii Domestic Abuse Shelter (WHDAS) are the only shelters on Hawaii Island to serve the immediate needs of residents seeking safety from domestic violence. The Hale `Ghana program provides emergency shelter to single women/men and those with children who are survivors of domestic violence (for a maximum of 120 days). The survivors accessing program services generally are fleeing from the geographic areas of Volcano to Puna, Puna to Hilo, and Hilo to Hamakua. Survivors from West Hawaii often access Hale `Ghana in East Hawaii for safety reasons. There are no restrictions to enter the shelter as long as the circumstances of need related to domestic violence are identified within 48 hours of entering the shelter. Hale `Ghana operates 24 hours a day/365 days a year including holidays, with staff monitoring and providing oversight of the safety and needs of the residents. The survivors are from all walks of life, and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment for participants. Our experienced staff will help families identify their needs, barriers associated with becoming self-sufficient, and develop plans to meet their needs and overcome barriers. The Hale `Ohana program offers education to residents on the dynamics of domestic violence, safe emergency shelter, emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, housing referrals, employability training and job search supports, TRO assistance, support groups, and personal planning based on individualized needs. Shelter staff also work with the survivors to build healthy relationships and strengthen their role as parents without using physical and/or verbal violence towards their children. We are committed to raising the consciousness of our society by educating our families on a violence free lifestyle; promoting family coping and stability; and providing a place of refuge. In addition, Hale `Ohana operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. The staff provides a safety assessment, makes recommendations and provides referral and resource information for callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from the increased stressors of the pandemic, poverty and homelessness across the island. The Hale `Ohana facility is set back from the roadway on approximately three acres of agricultural/residentially zoned land in East Hawaii, in a two-story home. The home has three full bathrooms, four bedrooms, with a capacity to serve 21 residents. The downstairs of the shelter facility has a laundry room that is accessed through the covered double car garage entrance. A comfortable sized living room and adjoining bathroom is accessible via the laundry room, and a short walkway connects this area with the spacious kitchen. There is an adjoining dining room and pantry which are also accessible via an entrance off the side of the kitchen that exits into the side yard of the property. Hale `Ohana is ADA compliant; it has an ADA ramp which leads to the lower floor where an ADA bedroom is located. The East Hawaii shelter is one of CFS' busiest shelters in the state. In the past three years the Hilo Shelter has served 722 participants. Page 1 of 3 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter FY18 FY19 ! FY20 Domestic Abuse # # FY18 # # FY19 # # FY20 Shelter Adults Children Total # Adults Children Total # Adults Children Total # Location Served Served Served Served Served Served 's Served Served Served East Hawaii 129 144 273 141 118 259 111 79 190 J West Hawaii 37 32 69 48 33 81 49 24 73 Honolulu 124 70 194 86 56 142 100 76 176 Leeward 123 54 177 79 71 150 78 65 143 6. Explain what plans your agency or program has to increase revenues to support this program: (Continued) We were also able to receive both DHS and DOH CARES funding to support the additional costs of PPE, provisions, sanitation, telehealth services and costs associated with creating additional outdoor spaces for social distancing. CFS will continue to remain vigilant with seeking and securing additional funding for the shelter program. 7. Program Objectives Using County Nonprofit Grant Program Funds (Continued): 80% of survivors will report that they are Mostly or Always confident in their ability to accomplish safety related goals, i.e., following through on safety plan. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake and at discharge. 80% of survivors will report that they are Mostly or Always confident that they have the support needed to move towards safety. 80% of survivors will report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in other areas (domains) of their life. In order to measure the last three objectives listed above, the Measure of Victim Empowerment Related to Safety (MOVERS) Scale survey will be given to survivors at intake, monthly thereafter, and at discharge. The program will provide the following activities to support victims with meeting the outcomes and objectives: • Support groups- Program staff will provide education regarding the dynamics of domestic violence • Safety planning-Program staff will discuss the different things to consider when making a safety plan. Staff will address safety concerns in multiple domains of the victim's life so that victims can adjust their plan to different situations. Staff will walk through step-by-step how to complete a safety plan with victims. Staff will inform victims of resources to keep safe and make referrals as requested Page 2 of 3 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter • Case Management-Program staff will provide case management to assist victims with identifying and securing safe housing, to connect with financial empowerment resources, to receive legal assistance and to increase their health and well-being. • Service Planning-Program staff will assist victims with identifying goals that they want to accomplish in the shelter program and with identifying the supports and resources needed to achieve their goals • Counseling- Program staff will provide supportive listening and solution focused counseling to assist victims with identifying barriers to achieving their goals and objectives and ways to problem solve. 8. Table I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results #of survivors that report that they are Mostly or Always confident in 96 their ability to accomplish safety related goals # of survivors that report that they are Mostly or Always confident 96 that they have the support needed to move towards safety # of survivors that report that they are Mostly or Always confident 96 that action toward the goal of safety will not cause new problems in other areas (domains) of their life. 12. Council Award Worksheet Table I (Continued) PROGRAM PERFORMANCE MEASURES Applicant Projected Results # of survivors that report that they are Mostly or Always confident in 96 their ability to accomplish safety related goals # of survivors that report that they are Mostly or Always confident 96 that they have the support needed to move towards safety # of survivors that report that they are Mostly or Always confident 96 that action toward the goal of safety will not cause new problems in other areas (domains) of their life. Page 3 of 3 Chile & Family Service West hlawai'i Alternatives to Violence 55 A - County of Hawa1 1 Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence Agency Director: Karen Tan Phone No.:(808 ) 681 -3500 Contact Person: Joey Keahiolalo Phone No.:(808) 681 —3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 81-6587 Mamalahoa Highway Address: Pualani Terrace, Bldg C City,ST,zip Kealakekua, HI 96750 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 —5280 Accountant/CPA: CW Associates, CPAs Phone No.:(808) 531 —1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Suite 1040 City,s-r,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑■ Hamakua ❑■ North Kona ❑South Hilo [' North Kohala ['South Kona ❑ North Hilo ❑■ South Kohala ■❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ■❑Youth ■0 Victims of Crimes ❑ Culture and the arts ❑Aged ❑� Victims of Health or Social Crises 111 Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $14,375(Island)$7,187.50(West Hawaii) $10,825(Island)$5,412.50(West Hawaii) $9,375 2.Agency Mission Statement: The Alternatives to Violence(AN)Program fits perfectly with Child&Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children." In partnership with the County of Hawaii,AN program services have been provided in Kona for more than nine years. CFS Kona offers 15 of our nearly 50 statewide programs with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.Those programs include Crisis Mobile Outreach; Domestic Violence Intervention and DV Shelter Services;Transitional Family&Crisis Homes;case management, prevention and treatment of commercial sexual exploitation of children and evaluation of exposure to domestic violence,as well as domestic violence and sexual abuse counseling services for children and their families. Infants,children,adolescents,individuals and families in need all have benefited from these services,as in Fiscal Year 2019, CFS directly served 15,901 individuals and their families,of all ages. In addition,the organization has"touched"the lives of over 75,000 individuals annually through hot-line calls,educational presentations,and providing food and clothing to those in need via the 35 sites on the various islands.In this timeframe,CFS Kona served more than 949 individuals and their families. (Continued on Attachment) 3. Program Description: Funding in the amount of$46,000 is being requested to support the total costs of the AN Program in the County of Hawaii.This funding will be used to support the following:(1)One part-time,20 hours per week, Domestic Violence Specialist IV(DVS IV)to provide counseling,TRO assistance,court advocacy,and co-facilitate Batterer Intervention groups and group assistance.This funding request would allow CFS to provide more efficient,timely and the much-needed DVS IV services in West Hawaii with the addition of an additional 20 hours of staff work time,increasing and expanding the services provided throughout the north,west, and southwest regions. Judiciary funding of AN was recently cut for all of Hawaii Island causing a reduction in available hours/days of services offered in Waimea and Kona.CFS's Waimea office was opened in 2017,in response to the community's direct request to provide TRO and domestic violence intervention locally.Community members expressed the difficulty for individuals to drive all the way to Kona or Hilo,and in fact this was a significant barrier to residents seeking vital services to protect themselves. CFS's primary funding and current cuts from Judiciary do not provide enough funding to support the Waimea office, needed staff,and the needed service operations. In Hawaii County,the demand for services has increased but our Judiciary funding has never been restored from funding cuts that occurred in 2009.Sadly,we have had to close the Waimea location effective 12/31/20 as the Judiciary also closed courthouse functions in Waimea. (Continued on Attachment) 4.Total Budget& Position Count: Total Program Budget: $350,600 Total Program Position Count: 3.75 FTE Total Agency Budget: $6,630,056 Total Agency Position Count: 87 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(Funding requested in this proposal) $46,000 Judiciary $169,069 HIUW $2,850 Program Fees $3,000 TOTAL: $220,919 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: CFS works hard to maintain,diversify and increase funding for our program services.Given the number of individuals and families impacted by domestic violence on the Big Island,domestic violence is a pressing public health and social welfare issue for our communities.CFS has sought and was also awarded Federal funding from The Violence Against Women Act (VAWA)and the Victims of Crime Act(VOCA)and various other charity grants to support our Domestic Abuse Shelter Programs(DAS). CFS has been challenged to maintain funding for the ATV Program.The program's primary funding source,the State Judiciary,decreased funding by 40%in 2009. In addition,there was a 20%cut implemented in 2020 despite the need for AN services increasing in quantity.CFS continues to seek funding from other sources to sustain these essential program services,as well as to meet the increasing need for services. Funding from the Hawaii Island United Way(HIUW)supports the Domestic Violence Intervention(DVI)component of ATV.Additionally,funding from the Annual Visitor Industry Charity Walk helps to support AN program services. (Continued on Attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: Overarching Goal:To change destructive behaviors and replace them with positive healthy behaviors and to assist survivors to seek protection. The following are the performance measures and achievements to achieve these goals: Measure&Outcome Achieved FY20-21 1.75%of participants will successfully complete Batterer Intervention-SAFE curriculum-60 successful completions 2.75%of participants who attend batterer intervention services will self-report that service has made a positive impact on their lives-60 positive responses EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence B.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Program Performance Measures: Applicant Projected Outputs FY20-21: #of individuals assisted with completing a TRO application 130 #of batterers who received domestic violence intervention 80 #of Court Assistance services provided 200 75%of participants will successfully complete Batterer Intervention-SAFE curriculum 60 successful completions 75%of participants who attend batterer intervention services will self-report that service has made a positive impact on their lives 60 positive responses (Continued on Attachment) Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $235,884 $236,000 $37,034 Professional Fees Operations $75,300 $75,500 $7,864 Supplies $6,000 $6,000 $382 Equipment Other: Participant Assistance-Trauma Support/Sustenanrj $1,005 $1,100 Other: Rent and Utilities $31,819 $32,000 $720 Other: Other: Other: TOTAL $350,008 $350,600 $46,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council El Staff appointed by a member of the Council Di The Mayor O The Managing Director II The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. Nthitt(:) 1/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in thea application, except for a 0 pp p maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ofitadt) 1/29/2021 Signature of Authorized Person Date Chief Performance Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Alternatives to Violence 12. COUNCIL AWARD WORKSHEET TABLE I: ApplicantProposed Council Pro osed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result #of individuals assisted with completing a TRO application 130 #of batterers who received domestic violence intervention 80 #of Court Assistance services provided 200 75%of participants will successfully complete Batterer Intervention-SAFE curriculum 60 successful completions 75%of participants who attend batterer intervention services will self-report that service has made a positive impact on their lives 60 positive responses TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $37,035 Professional Fees Operations $7,864 Supplies $382 Equipment • Other: Participant Assistance Other: Rent & Utilities $720 Other: Other: Other: TOTAL $46,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Attachment Applicant: Child & Family Service Program: West Hawaii Alternatives to Violence 2. Agency Mission Statement(Continued) During the current fiscal year, we have added the Festival of Hope in various locations that are free "pop up" events to distribute Lokahi bags of toys, games, food and information about community resource availability for all services for all age groups. Our DVS IV staff completed discreet screenings for risks of domestic violence during these events making needed connections for support services. Since COVID conditions restrict residents' abilities to gain free access to information including safety planning, CFS has worked to bring these resources directly to participants and their communities. To date we have brought this to 4900 statewide participants and on Hawaii Island alone we have served 1,250 in these events. CFS establishes goals to achieve mission impact through our strategic planning process involving all levels of the organization, including participants, community stakeholders, direct service staff, management and the Board of Directors. Our main goals for our participants and families are to: (1) Improve their emotional resilience; (2) Increase economic security; (3) Achieve educational success; (4) Increase social connections and support; (5) Increase feelings of safety; and (6) Increase independence and community engagement. As a family-centered, full-service organization, CFS has established four focus areas to reach our goals including:Welcome Families (Developing Family-friendly Points of Entry; Walk With Families (Developing Integrated Family and Community Partnerships); Meet Families Where They Are (Providing Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrating Impact and Sustaining Gains). We accomplish these goals while modeling the positive values of HOPE: Humility, Ownership, Perseverance, and Engagement. 3. Program Description (Continued) One solution Kona staff are implementing immediately to this adjustment is to be creative in offering "pop up" assistance locations at free sites throughout the north, west and southwest areas of the island for all of the ATV services we can offer. Our first anticipated "pop up assistance" event is planned for early February 2021. We are excited that this may result in opportunities to better serve our communities and really meet participants where they are at! The Alternatives to Violence Program provides an array of services for individuals who are survivors of domestic violence and their children, youth who are aggressive and or engage in bullying, abusive behavior, and for men and women who abuse. The primary result for our program participants is to recognize that domestic violence in intimate relationships generates disrespect and harm that is inconsistent with the values, beliefs, and conduct of every culture. Our desire is to end domestic violence through providing services, partnering with community resources, and participating in community education about domestic violence, thereby creating a tipping point in our community awareness that healing from trauma is an imperative, and we can't tolerate domestic violence or its effects. Domestic violence has traumatic impact on every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) indicate that 1 in 3 women will experience domestic violence during her lifetime;1 in 6 women will experience stalking; and in the U.S. more than 27% of women have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime. Of women experiencing domestic violence, 57% have symptoms of Post-Traumatic Stress Disorder(PTSD) leading to on-going mental health stressors and life impacts. Page 1 of 4 Attachment Applicant: Child & Family Service Program: West Hawaii Alternatives to Violence According to the Department of Housing and Urban Development (HUD); more than 7.2 million children witness domestic violence annually; children who live in homes with domestic violence also suffer abuse and neglect at high rates (30%-60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. The following ATV program services are included in the DVS IV job duties: 1) The DVS IV will assist with Temporary Restraining Orders (TROs). This is often the first step victims will take to increase their safety and the safety of their children. In addition to assisting individuals with completing to successful application for a TRO, program staff counsel, talk with victims about how to make a safety plan, provide a brochure on how to develop and use a safety plan for all family members, assess the victim for risk of further domestic violence and inform victims of their options to stay at a domestic violence shelter; 2) Court Advocacy for program participants during a TRO hearing in Family Court: This service would be added where possible and performed by the DVS IV; 3) Case Management for victims and facilitation of referrals and warm linkages to community resources that will assist victims with re-building their lives. The DVS IV oversees connecting participants to vital community partners for additional needed resources to support them in enhancing protective factors. This service will likely be expanded when requested by participants or initially through our pop up assistance events, and then continued by appointment; 4) Facilitating support groups for individuals who have been involved in domestic violence. This service would be performed by the DVS IV, and 5) Facilitating Domestic Violence.Intervention groups for those who abuse. To end the cycle of domestic violence and help families to fully heal, it is critical that those who perpetrate the violence receive comprehensive treatment to include group education and intervention and case management. In many cases, perpetrators of domestic violence were themselves victims at one time or another in their lives and domestic violence is deeply entrenched within their childhood upbringing and is how they habitually cope with stressors. Supporting offenders in their development of alternative coping strategies is a primary goal of the Domestic Violence Intervention groups. CFS closely adheres to the Hawaii Batterers Standards to include providing 26 weeks of intensive group intervention that focuses on holding the batterer accountable for their behavior, educating participants about the different forms of domestic violence, increasing participant's awareness of their own thought patterns and triggers-for abuse, helping participants to understand the relationship between thought and behavior, providing hands-on strategies for changing unhelpful thoughts and/or interrupting learned responses of reacting immediately and in abusive ways (i.e. choosing to take a cool down rather than responding right away), and facilitating opportunities for social support with other group participants who understand what it is like to struggle with domestic violence. All CFS Hawaii Island ATV program sites utilize the Stop Abuse For Everyone (SAFE) curriculum for the men's Domestic Violence Intervention (DVI) program. This is a curriculum that incorporates evidence-based components including motivational interviewing, cognitive behavior therapy and the change theory into our work with offenders. There are separate DVI groups for women and adolescents. All CFS AN program services are provided through the lens of trauma-informed care. We follow the Risking Connection®model which was developed by the Sidran Institute, to work with Page 2 of 4 Attachment Applicant: Child & Family Service Program: West Hawaii Alternatives to Violence individuals and families who have experienced trauma. This model provides a foundation for all the work we do with families and emphasizes the RICH® relationship approach where we offer "Respect, Information Sharing, Connection, and Hope" to everyone we engage within services. In alignment with evidence-based practices and a trauma-informed care framework, staff operate with the understanding that: • Traumatic events such as abuse can cause overwhelming feelings of horror, terror, and hopelessness; • Caregivers with histories of trauma may avoid experiencing their own emotions, which impacts and hinders their ability to respond appropriately in the present to their child's emotional state and needs; • Traumatic stress occurs when exposure to traumatic events overwhelm the individual's ability to cope, triggering additional symptoms of PTSD; • A strong relationship with a trusted caregiver is a potential buffer or protective factor against traumatic stress for children; • Positive attachment and connections are essential for healthy child and adolescent development; and • Working with families that have experienced abuse and trauma impacts staff, who may also need to be supported and nurtured in order to avoid "burn out." • AN program participants are encouraged to access services and resources that can help them to break the cycle of violence and move forward to lead safer, healthier lives. CFS hopes to be able to better meet the needs of our community by increasing and expanding AN services in West Hawaii County and all surrounding north and southwest environs. 4. Total Budget and Position Count(Continued) The ATV program in Kona consists of a Program Director II, Two DVS II's (16 hours per week ea.) assisting with calls/walk ins for TRO support at our Kona location, Tuesdays and Thursdays 8a.m. — 1p.m., with the Waimea coverage ending as of 12/31/20, now changing into 'pop up assistance." The DVS II also assists with intakes for DVI services as current funded hours will allow and supports PD II in report processing and data tracking. The AN program staffing also includes two DVS IV's (one 26 hours and one 12 hours)who facilitate both the Men's and Women's Domestic Violence Intervention groups, conduct intakes, counseling, safety planning, provide case management and collaborate with referral sources for data collection. The 26 hour DVS IV serves the Youth Services Program referrals as well. The 12 hour DVS IV provides court advocacy and assists with training and oversight for TRO processing and Court Advocacy • as well as the other duties defined above. Program Director II serves as back up for the direct service providers, and the Director of West Hawaii Island backs up the Program Director II. 6. Explain what plans your agency or program has to increase revenues to support this program (Continued) CFS does collect a group fee of$300 for our Domestic Violence Intervention program. This covers all 26 groups, a workbook and a certificate of completion. (This fee can be waived and replaced with work exchange for indigent or unemployed program participants, although COVID again is disrupting this option). CFS maintains high accountability to the participants we serve, the community and to our funders. CFS uses Results-Based Accountability (RBA)T"", a decision-making framework, to demonstrate that we are making an impact in the lives of the individuals and families we serve. RBA follows a simple, commonsense process, builds collaboration and consensus, and uses Page 3 of 4 •L Attachment Applicant: Child & Family Service Program: West Hawaii Alternatives to Violence data and transparency to ensure accountability. RBA asks 3 questions: How much did we do?; How well did we do it?; and Is anyone better off? Positive participant outcomes leadto better community health, safety, well-being and productivity. RBAT"" is a rigorous and dynamic process that requires a willingness for our organization to really look at the truth of how we are performing and the impact of our services. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATm will encourage funders to invest in our programs. CFS is committed to remaining a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will attract additional funding resources. 8. TABLE I (Continued) Our activity target of assisting 130 individuals with successfully completing and submitting a TRO application to the courts means that 130 survivors and their families will have achieved legal protections to prevent them from suffering further violence and from that violence spilling out to impact our communities. Since few ordinary people are familiar with the legal system, its requirements, or how to self-advocate in session this service is invaluable to survivors in submission of a factual, heart-felt plea for the court to grant protection. An affordable attorney many not be within reach for them. The benefit to our communities goes beyond this individual as it gives court authorized basis for the local police to provide protective actions in any setting of the survivor—work, school, child care center, public places—preventing acts of violence by perpetrators in these sites. When individuals are identified as batterers, they have our services opened up to them to gain education about domestic violence, about improving communication and relationships, about their own family histories and how to grow forward into a better future. The SAFE curriculum and domestic violence interventions assist individuals to be better partners, better employees or employers, better neighbors, and hopefully better advocates for a more peaceful community. If every year CFS Kona assists 80 batterers to find a less violence-filled life then gradually our communities, our workplaces, our shopping venues, our schools and day care centers become more peaceful places. Page 4 of 4 Child & Family Service West Flawai'i Domestic Abuse Shelter 56 t County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter Agency Director: Karen Tan Phone No.:(808 ) 681 —3500 Contact Person: Joey Keahiolalo Phone No.:(808) 681 —3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,sr,zip Ewa Beach, HI 96706 Facility Address: Address: 81-6587 Mamalahoa Highway Address: Pualani Terrace Bldq C city,sr,zip Kealakekua, HI 96750 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 —5280 Accountant/CPA: CW Associates, CPAs Phone No.:(808) 531 —1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Suite 1040 city,sr,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑l Hamakua ❑■ North Kona ❑South Hilo ■❑ North Kohala [1]South Kona ❑ North Hilo ['South Kohala ❑ Ka 16 Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Li Youth ■❑Victims of Crimes ❑ Culture and the arts Q Aged ■❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,050 $11 ,730 $10,875 2. Agency Mission Statement: Child&Family Service(CFS)is guided by this mission statement:"Strengthening families and fostering the healthy development of children." The organization's main service targets are to: (1)improve an individual's functional and coping status(emotional, psychological well-being,development and independent living skills); (2)improve individual or a family system's ability to cope with stressors in their life; (3)improve the health,welfare,and safety of individuals so that they are free of harm,abuse and neglect. The strategic vision of CFS is to become a family-centered,full-service organization including the values of Cultural competence;Person-and Family-Centered Approaches; Community and Stakeholder Partnerships;Trauma Informed Care; Positive Client Outcomes;Commitment to Learning;Quality Monitoring; Employee Excellence,and Coordination of Care.The organization has established four focus areas to fulfill this vision, namely,Welcome Families(Develop family-friendly points of entry);Walk With Families(Develop integrated family and community partnerships);Meet Families Where They Are(Provide adaptive and culturally appropriate practices);and Prove Effectiveness(Demonstrate impact and sustain gains). (Continued on Attachment) 3. Program Description: The West Hawaii Domestic Abuse Shelter(WHDAS)program,also known as Aunty's House, provides emergency shelter to families as well as single women and men,who are victims of domestic violence. Program capacity allows for a stay up to 120 days if all expectations are met throughout shelter stay and residents are able to maintain communal type living. Aunty's House supports domestic abuse victims from the geographic areas of Honoka'a to Waimea/Kohala region; Kohala to Waikoloa and the Kailua area,South Kona down to Naalehu and Naalehu through the Kau/Pahala area. For safety reasons, participants may also be housed in Aunty's House who cannot securely remain housed in Hilo;or may be transferred to our shelter on Oahu for their protection. Hawaii Island Domestic Abuse Shelters operate 24 hours per day, 365 days per year including holidays,with staff answering the required hotline as well as monitoring and providing oversight of the safety and needs of the residents.The victims are from all walks of life,and socioeconomic backgrounds, and all neighborhoods of Hawai'i County.The ultimate goal is to ensure that survivors locate and access stable and safe housing for themselves and their children. Key areas of focus for the Shelter staff are strengthening each individual's protective factors,offering support with safety planning,obtaining safe permanent housing, healing from trauma for both the victim and their children,and support groups for both adults and children.Typically,the funding for the Domestic Abuse Shelters is limited and does not provide for the program to have more than one staff available on shift. (Continued on Attachment) 4.Total Budget& Position Count: Total Program Budget: $550,650 Total Program Position Count: 6.95 FTE Total Agency Budget: $6,630,056 Total Agency Position Count: 87 FTE (Continued on Attachment) EXHIBIT A r NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(Funding requested in this proposal) $30,000 Department of Human Services $345,250 Department of Human Services-FVPSA Cares Act $3,875 HIUW $6,930 Department of Human Services BESSD HPO Emergency Shelter Grant $20,000 Attorney Generals Office-VAWA $75,000 (Continued on Attachment) TOTAL: $481,055 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS has a strong history of fundraising and is committed to continuing to grow our private donations and grants.We apply for all alternative funding sources possible for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life. 7. Program Objectives Using County Nonprofit Grant Program Funds: The main objective is that survivors will reduce exposures to violence,enhance their resiliency,build upon their social connections with increased supports to gain secure&safe housing. Kona staff work towards these objectives by providing adult's&children's support groups at the shelter.These groups focus on safety education and safety planning;positive behavioral supports,and individual time for each child to receive care for their needs around domestic violence and residing at the shelter.The children's groups also provide a space for appropriate arts and crafts designed for the developmental stage of the children to mitigate the effects of domestic violence.The DVS IIs provide aftercare for discharged residents and their children assisting them to successfully transition out of the program into safe housing in the community. Child&Family Service has created an RBATM scorecard for the WHDAS to achieve targets in FY 21 and ongoing in three areas as follows: %of survivors with no incidents of violence with his/her abuser in the past seven days—Goal Target:70%;Achieved 69% %of survivors who have a secure and safe place to go at discharge—Goal Target:70%;Achieved 21% %of survivors will enhance their resiliency—Goal Target:75%;Achieved 82% (Continued on Attachment) EXHIBIT A NONPROFIT GRANT APPLICATION -FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter • 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific) Program Performance Measures: Applicant Projected Results: #of bed days provided(adults&children combined) 5,500 #of participants in FY 21,both adults and children 100 %of survivors with no incidents of violence with his/her abuser in the past seven days 70% %of survivors who have a secure and safe place to go at discharge 70% %of survivors will enhance their resiliency 75% (Continued on Attachment) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $312,675 $336,400 $23,726 Professional Fees $125 $150 Operations $103,089 $107,000 $4,769 Supplies $13,144 $13,200 $250 Equipment Other: Participant Assistance - Emergency Shelter needs $12,699 $12,700 $250 Other: Food for Shelter Participants $15,183 $15,200 $400 Other: Rent and Utilities $65,1.66 $66,000 $605 Other: Other: TOTAL $522,081 $550,650 $30,000 *lf applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the_County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council In Staff appointed by a member of the Council O The Mayor DI The Managing Director • The Director of Finance co The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. • Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. G - 1/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: west Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. • As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 /29/2021 Signature of Authorized Person Date Chief Performance Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Child & Family Service Agency Name: Program Name: West Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of bed days provided (adults & children combined) 5,500 #of total participants (adults and children combined) 100 %of survivors with no incidents of violence with his/her abuser in the past seven days 70% % of survivors who have a secure and safe place to go at discharge 70% % of survivors will enhance their resiliency 75% TABLE 11: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $23,726 Professional Fees Operations $4,769 Supplies $250 Equipment Other: Participant Assistance $250 Other: Food for Participants $400 other: Rent & Utilities $605 Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 2. Agency Mission Statement(Continued) To realize our vision, we have organized our programs into four impact areas that include "Caring for Keiki, Healing From Trauma, Empowering Youth, and Honoring Kupuna." Proving the effectiveness of our programs is the ultimate achievement within these four programs focus areas. CFS demonstrates our commitment to service excellence and quality care through the provision of services that reflect HOPE: Humility, Ownership, Perseverance and Engagement. Child & Family Service's strengths lie not only in the organization's size and ability to share expertise and resources statewide, but also in our ability to adapt services so that they are unique and appropriate to the island, communities, and individuals we serve. CFS has years of experience working with the diverse demographics and cultural identities of Hawai'i's residents while partnering with funding sources to implement new models of service delivery to address changing social needs. 3. Program Description (Continued) In order to provide those additional services and desperately needed supports to achieve self- sufficiency, CFS must find supplemental funding. The limitation of the program time frame creates a situation in which the residents and staff are working very diligently and quickly to achieve housing and safety. When there is only one Shelter Services Advocate scheduled, it is very challenging to provide support services beyond emergency shelter to approximately 20 participants daily, while maintaining the 24-hour DV caller hotline that is required. If not for multiple streams of other funding, the DAS programs would not be sustainable. CFS's two Hawaii Domestic Abuse Shelters including Aunty's House (WHDAS) are the only shelters on Hawaii Island to serve the immediate needs of residents seeking safety from domestic violence and its related crimes. Domestic violence is traumatic, impacting every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) indicate that 1 in 3 women will experience domestic violence during her lifetime;1 in 6 women will experience stalking; and in the U.S. as a whole more than 27% of women have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime. Of women experiencing domestic violence, 57% have symptoms of Post-Traumatic Stress Disorder(PTSD) leading to ongoing mental health stressors. According to the Department of Housing and Urban Development (HUD); more than 7.2 million children witness domestic violence annually; children who live in homes with domestic violence also suffer abuse and neglect at high rates (30%-60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. Through current research we know that children of domestic violence have difficulty processing what has happened, their internalized feelings are displayed in behaviors as guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can continue to be involved in the cycle of violence when they are older. We also know that intimate partner violence is often unreported or underreported due to shame or embarrassment. Nevertheless, CFS program staff work to address these issues in participant's lives to the extent that funding and staff availability allow. Page 1 of 3 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 4. Total Budget& Position Count(Continued) Currently, WHDAS (Aunty's House) is funded for the following staffing pattern: one (1) 1.0 FTE Shelter Manager, three (3) 0.75 FTE Shelter Services Advocates (one vacant), one (1) 0.50 FTE Shelter Services Advocate. WHDAS is requesting County of Hawaii funding of$30,000 to assist in supplementing staffing with the addition of one PT (0.50 FTE) Shelter Services Advocate for hot line coverage and resident support including intake, service plans, counseling needs or relocation assistance into safe permanent housing in the community. When there are insufficient numbers of Shelter Services Advocates to provide the 24/7 crisis hotline coverage and basic monitoring, the Domestic Violence Specialist IIs (DVS II)will step in to cover; however, their valuable services to the shelter residents are then constrained or reduced accordingly. Additional funding from AG VOCA is currently supporting, but not consistently sustained, for DVS IIs—two (2) 0.60 FTE at 24 hours each; one (1) at 0.5 FTE, one (1) at 0.30 FTE and one (1) TSN; for DVS IV—one (1) 0.20 FTE at 8 hours per week; and Shelter Services Advocate—one (1) 0.60 FTE for 24 hours per week. The DVS II positions provide highly valued services including adult and children support groups at the shelter. These groups focus on safety education/planning (with personal safety being the key component); positive behavioral supports, and individual time for each child to receive support for their needs around domestic violence and residing at the shelter. The children's groups also provide a space for appropriate arts and crafts designed for the developmental stage of the children. The DVS IIs provide aftercare for discharged residents and their children. For FY 20 Aunty's House staff provided aftercare support for 11 families that were able to successfully transition out of the program into safe housing in the community. This includes purchasing items that are needed for a successful transition into their own housing. As intended, the DVS II is available to support residents and provides transportation for community engagements such as for housing appointments, mental and physical wellbeing, school concerns, shopping for basic needs, as noted above provides aftercare when requested, assist with managing donations to the program, having a flexible schedule to ensure staffing coverage for all shifts, and offers peer counseling to all residents as needed. 5. Program Funding Sources (Continued) Current funding for the Hawai'i Island Domestic Violence Shelters including WHDAS (Aunty's House) is a combination of state, federal, private donors, charity donors, as well as Hawai'i County grant awards. We gladly accept private donations and corporate donations also of goods such as the school back pack with supplies distribution; celebrations meals such as the annual Thanksgiving meal donation; Santa's visit to the shelter; the personal goods and diaper supplies donations; giving valuable time donations that are received during our annual Domestic Violence Vigil, sign waving, and walk in Kona services. Our employees participate in the yearly Charity Walk and other sponsored HIUW events. For two years CFS Kona has hosted the National Victims of Crime Rights Week awareness campaign. We work collaboratively with our stakeholders and fellow non-profit agencies in supporting and giving back in full measure across all demographic lines. • 7. Program Objectives Using County Nonprofit Grant Program Funds (Continued) The review of our accomplishments versus target shows the conditions in the West Hawaii area are changing and becoming much more difficult specifically with regard to survivors having a Page 2 of 3 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter "secure&safe place to go at discharge' and in their ability to achieve "no incidents of violence with his/her abuser in the past seven days." Though not shown, the increase in bed days indicates that survivors are needing to remain longer in the shelter in order to achieve safe and secure housing. We measure these results by the achievement of targeted steps to these goals and by participant self report. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS will remain a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will demonstrate the need as well as attract additional funding resources to address the specific needs of this population. 8. Table I: What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued) When survivors are assisted immediately with safe shelter, they are able to calm themselves and their children while seeking physical protection. Since they may have fled with only their present clothing, Aunty's House provides them with immediate needs. Our counselors help them to reduce distress, to understand what has happened and that everyone deserves safety. Our Kona staff assist them to find safe self-sufficient housing. When 100 participants yearly in west Hawaii achieve safety, safe housing, and violence-free lives in our community, then fewer individuals become homeless, parents & children stay together, more children can stay in, and focus on, their school without distress, and these survivors are helped to rebuild a productive, engaged life in the community. We are often able to provide aftercare follow up and are thrilled to hear success stories from our former participants as they grow and lead happier lives. Page 3 of 3 Children's Law Project of Hawaii, The Project Permanence: Guardianships and Adoptions for At-Risk Kids 57 County of Hawai`.i Nonprofit Grant Application FY2021-22 Agency Name:-The Children's Law Project of Hawai'i Program Name:Project Permanence: Guardianships and Adoptions for At-Risk Kids Agency Director: Valeie'Grab, ESq , EXee0ltiVre DII'e-ctor Phone No.:( 808 )959 — 2574 Contact Person: Valerie Grab, Esq., Executive Director Phone No.:( 808 ) 959 — 2574 Mailing Address: Address: The Children's Law Project of Hawai'i Address: PO Box 6249 City,ST,Zip Hilo, HI 96720 Facility Address: Address: The Children's Law Project of Hawai'i Address: 101 Aupuni St.,Ste. 1014A City,ST,Zip Hilo, HI 96720 Email Address: valerie.grab@clphi.org Fax No.: ( ) — Accountant/CPA: Sandra Silva Phone No.:(808 ) 936 — 1925 Firm (if applicable): Mailing Address: Address: cpa@sandrasilvacpa.com City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua Q North Kona Q South Hilo Q North Kohala Q South Kona Q North Hilo Q South Kohala Q Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 Not applicable $9,250 $11,850 • 2. Agency Mission Statement: Every child has a voice. The Children's Law Project of Hawaii("Children's Law Project")is dedicated to providing holistic advocacy services for court-involved children and youth, children at-risk of child protective services involvement, and their caregivers. Our organization is staffed by experienced family law attorneys, paralegals and social workers who are well-versed in addressing the legal needs of our young clients. The Children's Law Project serves all of Hawaii County (with offices in Hilo and Kona) and our attorneys regularly appear in Hilo, Kona and Waimea family courts. Children's Law Project attorneys typically serve as court-appointed Guardians ad litem ("GALs")for children in foster custody,juvenile law violation, Persons in Need of Supervision and contested custody proceedings. We also assist children and families in danger of becoming court-involved. We advocate for children's best interests in a wide range of areas such as permanency(powers of attorney, guardianships and adoptions), special education, behavioral accommodation, mental health services and disability benefits. Using this more expansive legal approach, we aim to limit or eliminate family court interventions and ensure better overall outcomes for the children we serve. No-cost legal representation and guidance for our clients is needed now more than ever in order to respond to the COVID19 pandemic. Health, education, employment, and and other critical societal decisions are based on the health needs of our community. This has resulted in redefining the ways in which we assoicate with one another. We are still responsible for the underpriveledged youth in need of safe homes and Project Permanence seeks to ensure that children are with caring legal guardians responsive their needs. 3. Program Description: Every child deserves a family, every kid needs a home. The aim of Project Permanence is to establish adoptions and legal guardianships for sibling groups whose parents are not able to safely care for them. The Adoption Assistance and Child Welfare Act of 1980 recognized the importance of placing children with families. [1] When removed from their parents, children do best in families. Living in families, regardless of whether those families consist of relative or foster caregivers, is critical to a child's success and supports their physical, emotional and social development needs. [2] Children's Law Project launched Project Permanence in August 2018, funded in part by a Hawaii County Nonprofit Grant. Our attorneys represent non-parent caregivers in guardianship and adoption proceedings, and in the last six months have finalized guardianships for 4 children and adoptions for 5 children. We also initiated guardianships for 11 children and adoptions for 6 children. We first seek to prevent family court involvement by establishing a legal relationship between children and non- parent caregivers prior to the need for child protective services interventions. Project Permanence also seeks to help children in foster custody. Through assisting foster caregivers in establishing guardianships and adoptions, court-involved children are more likely to live in permanent homes and forge lifelong connections to stable families. [1] See Adoption Assistance and Child Welfare Act of 1980, Pub. L. 96-272, 42 USC§675(2012), visit www.gpo.gov/ fdsys/pkg/USCODE-2011-title42/pdf/USCODE-2011-title42-chap7-subchap IV-partE-sec675.pdf [2]The Annie E. Casey Foundation, Kids Count Policy Report, Every Kid Needs a Family(2015) at: http://www.aecf.org/ m/resourcedoc/aecf-EveryKidNeedsAFamily-2015.pdf 4. Total Budget & Position Count: Total Program Budget: $60,000 Total Program Position Count: 7 Total Agency Budget: $606,500 Total Agency Position Count: 8 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Grant-in-aid $20,000 State of Hawaii Department of Human Services Non-Reoccuring Permanency Expense Reimbursement $30,000 Hawai'i Womens Legal Foundation (secured) $5,000 Children's Law Project $10,000 TOTAL: $65,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hawai'i Women's Legal Foundation awarded Project Permanence$5,000.00. Other potential funding sources include private organizations that support foster children and their caregivers, such as The Annie E. Casey Foundation, Hawaii Island United Way, Liliuok I ni Trust, and the Victoria S. and Bradley L Geist Foundation (through Hawaii Communitynit Y Foundation). Finally, Children's Law Project provides representation in legal guardianship and adoption matters on a sliding scale basis, and caregivers with financial resources are expected to contribute to the cost of Children's Law Project's representation and associated fees. We have also been working with the State of Hawai'i Department of Human Services in West Hawai'i to leverage Non-Reoccuring Permanency Expense Reimbursements to fund this work. 7. Program Objectives Using County Nonprofit Grant Program Funds: Project Permanence will secure adoptions and legal guardianships for 35 sibling groups whose parents are not able to safely care for them. Project Permanence provides attorneys to represent caregivers in uncontested adoption and guardianship matters. Project Permanence also works with a wide range of community partners and stakeholders, including the Hawaii State Department of Human Services, Hawaii State Judiciary, child welfare attorneys and foster caregiver associations and has developed a referral system. Project Permanence conducts informational sessions for community partners and stakeholders to explain the purpose of the project and how caregivers can be referred for representation. To facilitate representation, Children's Law Project attorneys assigned to Project Permanence developed retainer agreements, consents to release information, client questionnaires, guardianship and adoption petitions and other court- mandated documents necessary to finalize guardianships and adoptions. Children's Law Project attorneys regularly meet with caregivers to explain court processes and obtain the information needed to initiate legal proceedings. Attorneys remain in regular contact with caregivers to update them regarding their cases. Attorneys also attend court hearings with their caregiver clients and represent them in proceedings to establish legal guardianship or adoption. Uncontested legal guardianships and adoptions typically require one court appearance. After these proceedings, Children's Law Project ensures that all necessary court orders are in place and that any other necessary documentation (such as a revised birth certificate)is issued. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Representation of caregivers(foster and non-foster family)in legal guardianship Establish legal guardianships/adoptions and adoption matters for 35 sibling groups(same parents/ caregivers) Outreach to organizations supporting caregivers and continued evaluation and Referral of at least 35 caregivers in implementation of referral protocol need of guardianship/adoption Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $30,000 $50,000 $20,000 Professional Fees $5,000 $5,000 Operations $5,000 $10,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $40,000 $65,000 $20,000 *If applicable *(projected based on 2020 fiscal year) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 K , County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 0 Member or members of the Council 9 Staff appointed by a member of the Council 0 The Mayor El The Managing Director ® The Director of Finance 9 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: DI If no conflicts exist, check here. /1 )(Not/i.,-) \/-e r?i'v•et-ivY ) tAnvoivr Z 14)-7,/ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Flawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicoun -nonprofit-gra nt-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 111/11114 / -- `� ,il . Signature of Authori ed Person Date E ' t '"\/e - ' tr-rtv1/ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Representation of caregivers(foster and non-foster family) in legal guardianship Establish ega guartlianshipsatl°p qna and adoption matters tor a59"i''g°�°'S`�m°°a�'°" Outreach to organizations supporting caregivers and continued evaluation and implementation of referral protocol need of guardianship/adoption TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: • Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Children's Law Project of Hawaii, The Victim Options for Investigation, Child Empowerment and Safety 58 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Children's Law Project of Hawai'i Program Name:Victim Options for Investigation, Child Empowerment and Safety Agency Director: Valerie J. Grab, Esq., Executive Director Phone No.:( 808 ) 959 — 2574 Contact Person: Valerie J. Grab, Esq., Executive Director Phone No.:( 808 ) 959 — 2574 Mailing Address: Address: The Children's law Project of Hawaii Address: PO Box 6249 City,ST,Zip Hilo. HI 96720 Facility Address: Address: The Children's Law Project of Hawaii Address: 101 Aupuni St.,Ste. 1014A City,ST,Zip Hilo, HI 96720 Email Address: valerie.grab@clphi.org Fax No.: ( ) — Accountant/CPA: Sandra Silva Phone No.:( 808 ) 936 — 1925 Firm (if applicable): Mailing Address: Address: cpa@sandrasilvacpa.com City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ■❑ Puna ❑ Hamakua ®❑ North Kona ■0 South Hilo ■❑ North Kohala South Kona ❑■ North Hilo ❑■ South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ■❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities ■0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 i y County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 Not applicable Not applicable $12,850 2. Agency Mission Statement: Children need and deserve competent, independent and zealous attorneys to represent their best interests in family court proceedings, particularly when child abuse and domestic violence are alleged. The Children's Law Project of Hawaii ("Children's Law Project")is a 501(c)(3) nonprofit law firm with a mission of empowering children through youth- focused legal advocacy. The Children's Law Project was co-founded in 2017 by Executive Director Valerie J. Grab and Managing Attorney Madeline M. Reed, experienced litigators well-versed in child welfare and family law proceedings. Ms. Grab and Ms. Reed represented hundreds of children, parents and caregivers in foster custody,juvenile law violation and family law matters. They co-founded Children's Law Project to address systemic gaps experienced in advocating for court-involved youth. Our organization has expanded to include four attorneys,three paralegals and two part-time social workers. Every child has a voice, and Children's Law Project's specially-trained child welfare attorneys fight to ensure that the needs of court-involved children are not drowned out by surrounding familial conflict. Children's Law Project's attorneys represent children as Guardians ad litem("GALs"), lawyers charged with investigating the totality of children's circumstances and advocating for their best interests in Family Court. Children's Law Project's attorneys, however, are routinely appointed as GALs in a wide-array of family court cases and in addition to representing children in foster custody matters, we also serve as GALs in domestic violence, child abuse, truancy, guardianship and juvenile offender cases. Children's Law Project seeks to address the issues that necessitated Family Court involvement and ultimately prevent both Child Protective Services intervention and a child's placement in foster 3. Program Description: All children have a fundamental need to feel safe and secure in their home, and protected and cared for by the adults who surround them. Children's Law Project seeks funding for our Victim Options for Investigation, Child Empowerment, and Safety("VOICES") Program, which allows for the appointment of GALs by Family Court Judges on Hawai'i Island for court-involved children who are traumatized by domestic violence. GALs are of critical importance in child abuse and neglect cases and every child entering foster custody is immediately assigned a GAL to represent the child's best interests. However,there are countless children on Hawai'i Island who are victimized by experiencing and/or witnessing domestic violence,family violence, physical and sexual abuses, harrassment,trafficking, and custodial kidnapping. It is imperative these keTki whose futures are being decided before our courts in child custody proceedings, have the benefit of a specialized proponent to investigate the circumstances of the family, advocate for the children's best interests, and protect them. VOICES aims to provide these court-involved children with a GAL to confirm that they live in safe and appropriate homes where their fundamental needs are met. A spike in Temporary Restraining Orders and Civil Orders for Protection can be attributed to the COVID pandemic. The unprecendented time in which we are navigating has made clear that our families are in crisis and the child victims in these cases benefit from our GAL leadership. Typically,these referrals will come from domestic abuse cases(such as Temporary Restraining Orders or Civil Orders for Protection) and contested child custody cases in which domestic violence is present. Our legal expertise, knowledge of community resources and professional relationships allows us to serve as an independent liaison for family court judges.Acknowledging the distress of each client, we provide real, valid and effective recommendations for the Third Circuit Family Court. 4. Total Budget& Position Count: Total Program Budget: $145,000 Total Program Position Count: 7 Total Agency Budget: $606,500 Total Agency Position Count: 8 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate FY 2018 Victims of Crime Act Victim's Assistance Formula Grant(CFDA 16.575) $104,000 Atherton Foundation(secured supplemental Litigation Funds) $15,000 County of Hawaii Nonprofit Grant $20,000 Children's Law Project $6,000 TOTAL: $145,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: VOICES is primarily funded by a Victims of Crime Act("VOCA")grant which requires at least a 20%match of the total VOCA grant award. Children's Law Project requests$20,000 from the County of Hawai 'i Nonprofit Grant program to assist us in meeting the VOCA match requirement and sustain this critical program on Hawaii Island. Children's Law Project is reapplying for these VOCA funds in 2021 and if our VOICES program is again funded for the following two year period, the requested Hawai'i County financial support would greatly assist us in meeting the 20%match amount. If we are unexpectedly not awarded VOCA funds, we intend to utlitize Hawai'i County funds to continue to allow us to accept GAL appointments in these matters. Either way,support from Hawai'i County will help to sustain this crucial advocacy. The Children's Law Project is committed to the VOICES program and will continue to apply for and secure funding for this critical work. Our organization's plan to sustain the VOICES program after the 2020-2021 fiscal year involves diversifying our funding streams for the project and leveraging our program income from other sources to fund the work we do. Specifically, we have secured funds from the Atherton Foundation to expand the reach of our VOICES program by paying for experts and forensic consultations on difficult cases. We are also able to leverage our program income from our contract with the Hawai'i State Judiciary to help fund a variety of advocacy in our organization, including our work in VOICES with children exposed to domestic violence. 7. Program Objectives Using County Nonprofit Grant Program Funds: VOICES aims to serve child victims of abuse who are traumatized by domestic violence and who are the subject of contested child custody family court matters. Child clients will be selected for GAL appointment by Hawaii County Family Court Judges. Typically,these referrals will come from domestic abuse cases(such as Temporary Restraining Orders or Civil Orders for Protection) and contested child custody cases in which domestic violence is present. Children's Law Project proposes to complete the following objectives through VOICES during the 2021/2022 fiscal year: (1)Appointment of GALs for 20 sibling groups in contested family court matters involving domestic violence; (2)Sustainable implementation of referral protocol whereby any Hawai'i County Family Court Judge can appoint a Children's Law Project GAL in the family law cases involving domestic violence; (3)Collaboration and cooperation with the Hawaii State Judiciary, Third Circuit Family Court Judges and domestic violence/child abuse service providers to identify service gaps and community needs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Appointment of Children's Law Project GALs in contested custody matters alleging GAL appointment for 20 silbing groups domestic violence and/or child abuse Implementaiton of developed referral protocol for GAL appointment Implemented referral process with 20 sibling group GAL appointments • Collaboraion with Hawaii State Judiciary and community service providers Semi-Annual collaboration meetings Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $200,000 $110,000 $20,000 Professional Fees $2,000 $2,000 Operations $40,000 $27,000 Supplies Equipment Other: Travel/Conferences $6,000 $6,000 Other: Other: Other: Other: TOTAL $248,000 $145,000 $20,000 *If applicable *(projected based on 2020 fiscal year) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 } County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): • Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor O The Managing Director ® The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: D' If no conflicts exist, check here. 41( iJzil Signature of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. titAi PiVly 0i1,Li M /014Signature of Authorized Person Date �x (4 Ve. ( -rr-moi Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Children's Law Project of Hawai'i Program Name: Victim Options for Investigation, Child Empowerment and Safety 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Appointment of Children's Law Project GALs in contested custody matters alleging GAL appointment for 20 mbh ggroups domestic violence and/or child abuse Implementation of developed referral protocol for GAL appointment 20 9d'ng group GAL appointments Collaboraion with Hawai'i State Judiciary and community service providers S0m'Ann"alooIaboratanme2'ngs TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages $20,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Daniell R. Sayre Memorial Foundation, The The Daniel R. Sayre Memorial Foundation Tax ID 26-1097159 59 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name:The Daniel R. Sayre Memorial Foundation Tax ID 26-1097159 Agency Director: Laura A. Mallery-Sayre, Executive Directol�,hone No.:(606 )325 —5456 Contact Person: same Phone No.:(808) 640 —5456 Mailing Address: Address: KU. tiOX 1285 Address: City,ST,Zip Kallua-Kona, Hawaii 96145 Facility Address: Address: same Address: City,ST,Zip Email Address: mallerysayre@hawaii.rr.com Fax No.: ( ) - Accountant/CPA: Patricia Schumacher, CPA Phone No.:(808) 345 —19UU Firm (if applicable): Mailing Address: Address: 530 L. Hunt Hignway suite 103 1-'1V113 488 City,ST,Zip san Ian valley, Arizona 85143 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna Q Hamakua Q North Kona Q South Hilo Q North Kohala Q South Kona ❑■ North Hilo Q South Kohala Q Kali) Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts El Aged g Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: • Program Name: The Daniel R. Sayre Memorial Foundation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 2.Agency Mission Statement: -MISSION STATEMENT:The Daniel R. Sayre Memorial Foundation is a public 501 (C)3 non-profit whose mission it is to help to save lives on Hawai'i Island.Within this Mission,the Daniel R. Sayre Memorial Foundation strives to: (a) recognize and/or provide awards to members of the Hawaii County Fire Department for going above and beyond the call of duty; (b) raise and provide funding or equipment to Hawaii County Fire Department for the purchase of equipment and related training in the use of such equipment; (c) recognize and/or provide awards to youth participants in surfing events such as the Shane Dorian Keiki Surf Meet, as selected by the Directors for their outstanding sportsmanship and enthusiasm; (d) assist in supporting the Jr. Lifeguard Program in Hawaii County; (e) educate the public regarding ocean safety and assist in providing support for additional ocean safety programs in Hawaii.; (f) assist in the distribution of PPE to first responders and healthcare providers; (g) assist in the distribution of UV sterilizing units to first responders and healthcare providers; (h) assist in the funding of 100%COVID-19 testing at all airports on Hawaii Island. 3. Program Description: This grant application is specific for securing desperately needed water safety craft and training for the Island of Hawaii for the Ocean Safety Division of the Hawaii Fire Department. Please see the attached explanation of need as well as photographs of the current water safety craft. 4.Total Budget&Position Count: Total Program Budget: $69,015.78 Total Program Position Count: Total Agency Budget: Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 The explanation from the Hawaii Fire Department is as follows: We started our Rescue Watercraft program back on July 1, 2015. Since then we have conducted many lifesaving rescues for our local residents and visitors alike. The RWC program has proven to a truly valuable asset to our Operational responses for the Hawaii Fire Department, and has proven to be well worth it's cost. It has been 5 1/2 years since its inception, and our SKI's are at the end of their life span. "Our SKI operators and Maintenance shop personnel do their best to keep these valuable pieces of equipment operational, but the cost of maintaining them along with the amount of out of service time we are experiencing due to the frequent need for repairs are exceeding their current value. These SKI's are no longer considered to be an effective and dependable. The typical service life for an emergency response Rescue Water craft is 3.5 to 5 years depending on conditions. So we are just outside of that life span. Due to recent budgetary shortages, we have tried our best to keep these SKI's operational as long as we could. But we feel we have exceeded that potential. One of our East HI RWC has been out of service for almost half a year due to the cost of repairs and the frequency of it breaking down, out weighing the value of the SKI. Once we made the determination that we would not proceed with the repairs,we started to look for funding and began the procurement process to replace 2 of our 4 RWC. As we were in this process, our second East HI SKI was damaged beyond repair. It occurred while in the process of executing a rescue of a 13 year old boy who got into trouble while surfing here in Hilo during a recent High Surf event. We are glad to say that the boy was successfully rescued without injury and our operators also we not injured during this incident,but the SKI was damaged by the pounding surf. See images attached. That being said we are out of 2 SKI in East HI. In attempt to maintain service on the East side of our island we brought the backup SKI from West HI as a temporary replacement. However, upon conducting a maintenance run of the SKI to assure operational worthiness, it was determined that the impeller and drive shaft are in disrepair and need to be replaced. So currently we only have 1 of the 4 SKI's in operation. It is the front line SKI for West HI. We currently do not have a RWC in operation in East Hawaii. I think this shows our urgency and need for replacing the SKI's ASAP. We were hoping to be able to procure 2 SKI's through our normal budget and procurement process, and if we could get the other 2 through The Foundation efforts with this grant, it would bring our RWC program back to previous capabilities. The quotes for the Personal Water Craft along with the Rescue sled and Mounting hardware that we hope to acquire. We hope to get the following items through this grant 1. 2-Yamaha FXHO Waverunners 2. 2-HSA"The Standard"Rescue Sled 3. Rescue Watercraft Operator training that was previously requested to finalize getting our operators fully trained to be instructor, which in turn will allow us to conduct our own internal RWC Operator training. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: The Daniel R. Sayre Memorial Foundation 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate I ne uNSMI-ounaatlon is seeking support from eacn of I ne 9 Louncii uistrict; 4if,tibt3.42/ulStrI - or one lump sum from the County of Hawaii. TOTAL: $69,015.78 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This funding is for 2 Water Safety craft and sleds as well as the training of$30,900.00 quoted by the University of Hawaii. The Daniel R.Sayre Memorial Foundation is committed to providing funding for two additional Water Safety Craft and sleds that are currently needed in the amount of$38,475.78. It would be ideal to be able to double the request from the County Council in order to purchase 4 of the Water Safety Craft,therefore allowing the Daniel R. Sayre Memorial Foundation to purchase the additional 2 that are needed for a total of 6 for the Island as we have been made aware that even 4 is insufficient for the needs of the Ocean Safety Division. We did not wish to be over-reaching so we are asking for the minimum of two. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objective using County Nonprofit Grant Prgram Funds would be to immediately purchase the Water Safety Craft that are needed,to implement the training program and to once again have these life-saving measures available through the Ocean Safety Division of the Hawaii Fire Department. It has been demonstrated over and over again,that these units save lives and to not have these available is obviously not acceptable for the well-being of our community and guests alike that might get into harm's way. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: The Daniel R. Sayre Memorial Foundation 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific. 1. Erie water 5atety ( raft and sleds will be purchased immediately "2. The training for the Ocean Safety Officers will be implemented '�. Documentation of rescues and recoveries implemented 4. Hopefully mere will be more rescues man recoveries documented Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment $38,115.78 $38,115.78 Other: Training for Water Safety Craft Operators $30,900.00 $30,900.00 Other: Other: Other: Other: TOTAL $69,015.78 $69,015.78 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Program Name:The Daniel R. Sayre Memorial Foundation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the ' following (check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑ If no,conflicts exist, check here. r ) , January 27, 2021 Signa re of Auth• ized Pers (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name:The Daniel R. Sayre Memorial Foundation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of.Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes.- I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name:The Daniel R. Sayre Memorial Foundation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials,insurance or securities) on private properties unlessotherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 27,2021 5' nature of Aut orized Person Date Executive Director, The Daniel R. Sayre Memorial Foi. Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name:The Daniel R. Sayre Memorial Foundation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 East Hiwai`i Cultural Council EHCC Exhibition and Lecture Series, FY2021-22 61 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:East Hawai'i Cultural Council Program Name:EHCC Exhibition and Lecture Series, FY2021-22 Agency Director: Kellie Miyazu Phone No.:(808 )895 -6155 Contact Person: Carol Walker Phone No.:(808 )938 -7650 Mailing Address: Address: 141 Kalakaua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 141 Kalakaua Street Address: City,sr,Zip Hilo, HI 96720 Email Address: kmiyazu@ehcc.org Fax No.: ( ) — Accountant/CPA: Amy Paikuli Phone No.:(808 )989 -8499 Firm (if applicable): • Mailing Address: Address: PO Box 492622 City,ST,Zip Keaau, HI 96749 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds:$10,000 Geographical Areas To Be Served: (One or more can be checked) ■❑Puna Q Hamakua ❑ North Kona ❑South Hilo ❑■ North Kohala 0 South Kona ❑North Hilo ❑t South Kohala ❑■ KaTi Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ['Youth ❑Victims of Crimes • • Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑Physical/Emotional Disabilities • ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:East Hawai'i Cultural Council Program Name:EHCC Exhibition and Lecture Series, FY2021-22 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 0 0 • 2.Agency Mission Statement: The mission of EHCC is to give voice to the cultural and artistic expressions of the diverse communities that make up our island,especially underserved and overlooked groups such as LGBTQ,women,Native Hawaiians,and children.We also inspire creative thought by bringing Hawaii residents cultural enrichment from beyond our shores. We fulfill our mission through three pillars:First,our ongoing program of thought-provoking gallery exhibitions,for which this application seeks support.Second,a wide-ranging performing arts program that(when not restricted by pandemic conditions)features plays,musicals,multimedia productions,concerts,and storytelling.Third,an arts education program targeted primarily to children and youth that offers after-school classes,school break and summer day camps,and pop-up workshops,teaching everything from ceramics to digital photography to gyotaku(Japanese fish printing).Our cross-cutting activities include a newly initiated lecture series that offers presentations by the artists featured in our gallery,along with' talks by experts to enhance appreciation for the exhibited art. • 3. Program Description: Our gallery program principally features art from Hawaii-based artists,including feminist Mayumi Oda and the late Shingo •• Honda,who was affiliated with the Mono-Ha movement in Japan.Annual themes include shows devoted to native ' Hawaiian art,women,and LGBTQ,with curation by representatives of these groups.Two of our most popular recurring exhibitions deserve special mention:We present a juried Trash Art show that encourages local residents to recycle and be creative with discarded items.For over three decades we have hosted,in collaboration with the Department of Education, the Young At Art show.This exhibition,which offers awards and recognition to the island's talented children,showcases the work of 250 to 300 young artists each year. We also remain ready to adapt our programming to meet unexpected circumstances,such as when we went on line during the pandemic with a community photo exhibit that invited local residents to share their experiences through photography. The newest component of our gallery program is an associated lecture series,which we have launched despite pandemic conditions(using social distancing for in-person events and Zoom for an on-line lecture).Examples include a presentation/Q&A with Hawai'i-based artists Pier.Fichefeux and Daniel Sheinfeld Rodriguez;gallery tours by Phan Nguyen Barker to share the inspiration behind her"Walking Through Mist"exhibition;and the Zoom event,"Arts of Vietnam:An Historical.Introduction"by art historian and retired George Mason University professor Lawrence Butler. • When pandemic restrictions ease,we look forward to continuing our exhibitions,resuming our well-attended First Friday exhibition openings,and expanding our new lecture series. 4.Total Budget&Position Count: Total Program Budget: $52,020 Total Program Position Count: 3 Total Agency Budget: $97,040 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:East Hawai'i Cultural Council Program Name:EHCC Exhibition and Lecture Series, FY2021-22 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Individual donations $24,000 Gallery sales $4000 Membership dues S800 Grants $23,220 TOTAL: $52,020 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: • EHCC has both short-and long-term plans to increase revenues to support our gallery programming. In the short-term,we are focusing on improving our membership revenue and increasing our grant-writing.In the longer term,we intend to replace our gift shop,enhance the market for an art collection donated to us,and negotiate a trust agreement with a generous donor.These strategies are briefly described below. IMPROVING MEMBERSHIP REVENUE:The EHCC board has begun an analysis of our membership activities,to identify means of increasing membership(finding and utilizing entry points such as reaching out to all gallery visitors; creating and publicizing appealing member benefits)and if necessary updating our membership levels and fees. GRANT WRITING:To overcome our lack of personnel available to write grants,EHCC recently shifted Executive Director responsibilities to our Youth Art Series Coordinator,freeing up the outgoing ED to spend more time writing grant • applications such as this one. REPLACING OUR GIFT SHOP:Our gift shop,which in recent years has contributed only a small fraction of total revenues,has been permanently closed.Plans are underway to create a high-end showroom offering significant arf for purchase,providing a bridge between high quality Hawai'i artists and discerning collectors and interior designers.(Local artists interested in selling small items such as ceramic vases,formerly available in the gift shop,will still have the option of selling through the EHCC office.) ...Answer continues on additional page... 7. Program Objectives Using County Nonprofit Grant Program Funds: With County funds,EHCC will have sufficient revenue to undertake a year-long schedule of exhibitions and maintain the gallery,with all necessary maintenance and repairs,painting,and installation work conducted to a high standard.If funding permits,six to eight exhibitions,each in place for one to two months,will be produced,and are expected to include these shows: The annual Young At Art Exhibition(which will be in its 34th year in FY2021-22)includes art,sculpture and photography from 250 to 300 children in grades K-12 across the island of Hawai'i,including public,private,charter,and home-schooled entrants.Prizes are awarded to the most talented young artists,dignitaries such as the Mayor kick off the festivities,and more than a thousand visitors enjoy the whimsy and sometimes startling perceptiveness of young artists. A Hawai'i Contemporary Art Show(in its 5th year during FY2021-22)showcases Hawai'i artists.Each year is different, but there is always a focus on native Hawaiian art and culture.Past examples include"Niuhi-Shark:Honoring • Kamehameha the Great in Paint and Prose,"with paintings and book excerpts recounting important event's in the King's life;"The Leaping Place,"featuring photographs related to Kumulipo,the ancient Hawaiian creation chant;and a collaboration between EHCC and the Maunakea Visitor Information Station that produced two exhibitions by local artists who were inspired by areas of the mountain used for spiritual/ceremonial purposes,hunting and gathering,and astronomy. ...Answer continues on additional page... EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Pag e3 of 8 Agency name: East Hawai'i Cultural Council Program name: EHCC Exhibition and Lecture Series, FY2021-22 (continuation of text for County of Hawai'i Nonprofit Grant Application FY2021-22 6. Explain what plans your agency or program has to increase revenues to support this program (continued from form): Managing a donated collection: EHCC recently received a substantial collection of artworks by Shingo Honda (1944-2019), so that we can promote interest by museums around the world and strategically sell pieces as they increase in value. Creating a trust: EHCC is currently in negotiations with a donor who hopes to endow a sustainable, long-term trust to encourage visitors to participate in guided tours of art on view at EHCC and elsewhere on island. • • 7. Program objectives using County Nonprofit Grant Program Funds(continued from form): The Trash Art Show, a juried exhibition coming up on its 33rd year, encourages recycling and is one of EHCC's most popular activities,with dozens of experienced and first-time artists turning trash into witty and thoughtful paintings, sculpture and more. • In addition to these time-honored traditions,the EHCC gallery director hopes to produce provocative new shows such as an exhibition focused on LGBTQ individuals in the Pacific Islands and an ambitious collaboration with the Hawai'i Wildlife Fund to fill the gallery with ocean debris to stimulate deeper thinking about plastic waste. These exhibitions will be supported by artists'talks and lectures related to exhibition themes. For example, a wildlife biologist may give a talk to accompany the ocean debris exhibition, while a Native Hawaiian practitioner might speak on cultural practices during the Hawai'i • exhibit. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:East Hawai'i Cultural Council • Program Name:EHCC Exhibition and Lecture Series, FY2021-22 8.TABLE I: • What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Total number of gallery visits 4275 Percentage of visits made by repeat visitors 50% Total number of lectures/artist talks presented 8 Total attendance at lectures/talks 250 New member sign-ups from gallery visitors and lecture attendees 60 Average satisfaction score on survey forms 3.5 out of 4 Number of Big Island adult and child artists exhibited 330 Attach additional pages as necessary. • 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 28,650 32100 ,0 Profession al Fees 0 3850 3850 Operati ons 4520 5715 0 Supplies 2000 2750 0 Equ pment 0 1500 .1500 Other: Insurance 1380 1380 0 • • Other: Container rental 0 1325 1325 Other: Container transport 0 3400 3400 Other: Other: TOTAL 36,550 52,020 10,075 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Pag e4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:East Hawai'i Cultural Council Program Name:EHCC Exhibition and Lecture Series, FY2021-22 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please d isdose any coni cts or potential conii cts of interest that any board m em berg cer, director, or ad m nistrator of you roig anization m have with the County.of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): Q Member or members of the Council • ® Staff appointed by a member of the Council ® The Mayor O The Managing Director 0 The Director of Finance ® The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel • Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: RI If no conflicts exist,check here. � - I I 24 z s Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:East Hawai9 Cultural Council Program Name:EHCC Exhibition and Lecture Series, FY2O21-22 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records,reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents,is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit'a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:East Hawaii Cultural Council Program Name:EHCC Exhibition and Lecture Series, FY2021-22 i1.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by.the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance • or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. VI I 2 1 Signature of Authorized Person Date Kellie Miyazu, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 . Countyof Hawai`i Nonprofit Grant Application FY2021-22 Agency :East Hawai'i Cultural Council g Y Name:East Program Name:EHCC Exhibition and Lecture Series, FY2021-22 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES • Applicant Council Proposed Projected Results Projected Result Total number of gallery visits 4275 Percentage of visits made by repeat visitors 50% Total number of lectures/artist talks presented 8 Total attendance at lectures/talks 250 New member sign-ups from gallery visitors and lecture attendees 60 Average satisfaction score on surveyforms 3.5 out of 4 Number of Big Island adult and child artists exhibited 330 • TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 3850 Operations 0 Supplies 0 • Equipment 1500 Other: container rental 1325 Other: container transport 3400 Other: Other: Other: TOTAL 10,075 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Effective Planning & Innovative Communication, Inco HI HOPES Initiative HI HOPES Match 62 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name:HI HOPES Initiative HI HOPES Match Agency Director: Laurie A Tochiki Phone No.:(808 ) 218 —6886 Contact Person: Jeanne Hamilton Phone No.:(808 ) 227 —3171 Mailing Address: Address: 1130 N. Nimitz Hwy, Suite C-210 Address: n/a City,ST,zip Honolulu, HI 96817 Facility Address: Address: 101 Aupuni St, Suite 140 Address: n/a City,ST,Zip Hilo, HI 96720 Email Address: Jhamilton@epicohana.org Fax No.: (808 ) 838 —1653 Accountant/CPA: James D. Jennings Phone No.:(808) 942 —8813 Firm (if applicable): James D. Jennings, CPA, Inc. Mailing Address: Address: 615 Piikoi St., Suite 1507 City,ST,zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna g Hamakua ❑■ North Kona ❑® South Hilo Q North Kohala 0 South Kona ❑� North Hilo g South Kohala ■❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1.of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20 - 21 n/a n/a $4,750.00 2. Agency Mission Statement: Families are the foundation of our community, and their well-being is inextricably linked to the health and prosperity of the community,state,and nation. Effective Planning&Innovative Communication, Inc(EPIC'Ohana)works to strengthen'ohana and enhance the welfare of children and youth through transformative processes that are respectful,collaborative and solution-oriented. 3. Program Description: ' EPIC'Ohana provides the HI HOPES Initiative HI HOPES Match program in Hawaii County to support successful transitions into adulthood for young people who have been in foster care.The HI HOPES match program provides financial education and offers a hands-on approach to developing financial capability through matched asset purchase opportunities. Eligible participants are between the ages of 14-25,have spent at least one day in child welfare foster care after their 14th birthday, and live in Hawaii County.Participants take the Opportunity Passportni Participant Survey twice a year to remain active in the program. Participants complete an 8 hour financial literacy training(FLT),open a matched savings bank account at Bank of Hawaii,and can make a 1:1 match on developmentally appropriate assets.The FLT covers goal setting, budgeting, money management,and credit.Due to COVID-19, FLT is being delivered through online video conferencing. EPIC will continue to deliver FLT virtually until in-person gatherings are safe. Participants are eligible to receive matched funds up to$3,000 which can be accessed when they have saved at least half the cost of a pre-approved asset. Participants complete an application for the asset purchase, provide supporting documents, and then participant funds are verified by Bank of Hawaii. Pre-approved asset categories include post-secondary education and training, housing (first month's rent and security deposit),vehicles,microenterprise,credit building,and participant specific category. During FY 2019-2020, HI HOPES participants in Hawaii County matched$19,955 of their savings toward an asset purchase.Sixty-eight percent($16,007) of participant matches were dedicated to housing and vehicles. HI HOPES promotes stable housing and access to reliable transportation by matching participant funds for first month's rent,security deposit,electric and/or utilities deposit, and vehicle purchases. Our program budget below reflects Hawaii County operations. Requested funds will only be used for Hawaii County programming. 4.Total Budget & Position Count: Total Program Budget: $76,336.00 Total Program Position Count: 0.35 Total Agency Budget: $5888,292.00 Total Agency Position Count: 86 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii Department of Human Services $26,972.00 Victoria S.&Bradley L.Geist Foundation $32,128.00 Donations $2,000.00 Hawaii County Nonprofit Grants Program $10,000.00 TOTAL: $71,100.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The HI HOPES Initiative HI HOPES Match has secured funds from private foundations and receives support from the Department of Human Services.Small donations have also helped to fund the program. For the past year, HI HOPES has been working to build its capacity in fund development in order to seek additional streams of funding. Efforts in the past year includes building our social media presence as a form of communication to solicit donations, a virtual event to celebrate our 10 Year Anniversary with strong supporters as attendees,and the development of a fundraising and communications plan. Plans to increase revenues include continuing to develop our fundraising and communications efforts, as well as building our first database of donors.The Annie E Casey Foundation is currently providing technical assistance to EPIC to develop fund development capacities.Through CARES Act Funds, EPIC has made temporary hires in fund development and communications.This work is creating a strong foundation for organizational capacity to nurture donations.As EPIC develops this capacity to build long-term and sustaining resources, HI HOPES is seeking assistance from Hawaii County Nonprofit Grant Program Funds to help fill financial gaps. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objectives using county nonprofit grant program funds are to: 1)Establish Matched Savings Bank Accounts with young adults in the HI HOPES Match and seed the accounts with a beginning balance of$100.00. 2)Support matched purchases towards housing and vehicle purchases. Housing purchases include security deposit,first month's rent,and electric and/or utility deposits.Vehicle purchases include purchase cost of vehicle,downpayment for vehicle,one-time payment of car insurance together with vehicle purchase,and title and registration fee with vehicle purchase. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of participants enrolled into the HI HOPES match in Hawaii County. 20 Number of established Matched Savings Bank Accounts. 18 Number of matched asset purchases for housing and vehicles. 6 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $24,846.00 $22,393.00 $0 Professional Fees $4,080.00 $4,795.00 $0 Operations $22,089.00 $16,879.00 $0 Supplies $232.00 $480.00 $0 Equipment $139.00 $153.00 $0 Other: Housing &Vehicle Asset Purchases $13,600.00 $13,600.00 $10,000.00 Other: Matched Savings Bank Account Seed Deposits $1,800.00 $1,800.00 $0 Other: Financial Literacy Training $1,000.00 $1,500.00 $0 Other: Survey Incentives $7,600.00 $7,600.00 $0 Other: Estimate for other Asset Purchase Categories $950.00 $1,900.00 $0 TOTAL $76,336.00 $71,100.00 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 • Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist; one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor 11 The Managing Director L] The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 02/ Signature of Au horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused byJune 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. z3 ad �� Signature f Authorized Person Date President & CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Effective Planning & Innovative Communication, Inc. Program Name: HI HOPES Initiative HI HOPES Match 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants enrolled into the HI HOPES match in Hawaii County. 20 Number of established Matched Savings Bank Accounts. 18 Number of matched asset purchases for housing and vehicles. 6 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0 Professional Fees $0 Operations $0 Supplies $0 Equipment $0 Other: Housing &Vehicle Asset Purchases $10,000.00 Other: Matched Savings Bank Account Seed Deposits $0 Other: Financial Literacy Training $0 Other: Survey Incentives $0 Other: Estimate for other Asset Purchase Categories $0 TOTAL $10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Family Support Services of West Hawaii Fatherhood Initiative 63 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Family Support Services of West Hawaii Program Name:Fatherhood Initiative Agency Director: Ray Wofford Phone No.:(808 ) 466 —2026 Contact Person: Raymond Clough Phone No.:(808 )466 —2028 Mailing Address: Address: 75-127 Lunapule Rd. Suite 11 Address: City,sr,zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd. Suite 11 Address: City,sr,Zip Kailua-Kona, HI 96740 Email Address: rclough@fsswh.org Fax No.: (808 ) 326 —4063 Accountant/CPA: Phone No.:(808) 242 —5002 Firm (if applicable): Carbonaro CPA's & Management Group Mailing Address: Address: 1885 Main St. Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Hamakua ❑■ North Kona ❑South Hilo 0 North Kohala ❑� South Kona ❑ North Hilo ['South Kohala ■❑ Kai() Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth 0 Victims of Crimes ❑ Culture and the arts ❑Aged 0 Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 22,350 11 ,625 23,250 2.Agency Mission Statement: Family Support Hawaii(FSH)began in 1979 as a grassroots organization providing family support in communities throughout West Hawaii. FSH incorporated as Family Support Services of West Hawaii in 1981 as a private,non-profit organization whose mission is"To support families and communities in providing love and care for our children". This carefully chosen mission statement embodies two key elements: support for families and support for communities. The first element guides us in the direct work of supporting families through our home visiting,occupational,speech,and physical therapies, infant and toddler child development centers,parent education/support programs, services for fathers, breastfeeding support,and youth programs. The second element of our mission guides our work within communities to develop the capacity to provide a supportive environment for families and individuals. FSH works to achieve these elements through our community development activities,collaboration building,and advocacy work for a better quality of life for the people of Hawaii. Our mission statement encompasses the work that we do with dads,moms,grandparends, 'ohana caregivers,foster parents,infants,toddlers,youth,families experiencing homelessness,those who are disabled, disenfranchised,and those living in poverty. We strive daily to make a long-lasting positive difference in their lives. Our community-based,culturally-responsive services are rooted in a philosophy of collaborative empowerment to build stronger,healthier families. 3. Program Description: The Family Support Hawaii Fatherhood Initiative has been engaging West Hawaii families for over 15 years,serving fathers through support groups,special events,and advocacy in courts. The program utilizes the"24/7 dad curriculum" provided by the National Fatherhood Initiative. This 12 week workbook helps fathers understand the conscious and unconscious beliefs about being a father,and how those beliefs support or hinder their efforts to be good role models and partners. The skills and knowledge that fathers develop through the program support them to reflect,engage,and listen in order to maintain a healthy environment for themselves and their families. In addition the group format provides space fore men to challenge themselves and each other about the negative beliefs and norms that exist in our society regarding men and fathers. In addition to support groups,the program works to build mentor/mentee relationships between fathers who have demonstrated leadership in their communities or have positively progressed in the program,and new fathers entering the entering the program that are often experiencing struggles family court and visitation with their children. These peer-supported relationships help to support fathers outside the group setting towards the goal of reunification with their family,and building healthy co-parenting relationships the mothers of their children. The Fatherhood Initiative also works with other FSH and community programs to distribute educational information fathers in the community,as well as participate in socialization events with Early Head Start. 4.Total Budget&Position Count: Total Program Budget: $40,000 Total Program Position Count: 0.50 Total Agency Budget: $2,687,800 Total Agency Position Count: 36 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Hawaii Island United Way $4,120 County of Hawaii(Requested) $35,000 Community Donations $1,000 Castle Foundation(Supports Socialization Events) $3,000 TOTAL: 43,120 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Family Support Hawaii is committed to continuing services through this program scaled to available funding. While COVID-19 restrictions have led to a temporary pause in fundraising events, FSH continues to fund-raise through its website and direct mail campaigns. The program also seeks to leverage community support through in-kind donations when possible. FSH will continue to seek funding opportunities through community foundations including Hawaii Community Foundation,Atherton Family Foundation, Hawaii Island United Way,and others. • 7. Program Objectives Using County Nonprofit Grant Program Funds: The Fatherhood Initiative will provide support to fathers in the community with a focused curriculum to empower fathers to take positive steps towards becoming the loving caregivers their children need. To accomplish this,the Fatherhood Initiative will: -Provide Monthly Support Groups for fathers -Recruit Mentor Fathers to provide peer to peer support to new/struggling fathers. -Provide individual case management to fathers to address specific needs, such as establishing visitation rights with their children. -Provide educational material and resource referrals to fathers in the program and in the community at large. -Hold bi-monthly events to promote healthy father child interactions,awareness in the community,and extended family/community socialization. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Fathers will report improved understanding of their role as a father 90% Fathers will report improved relationship with the mother of their children 90% Fathers will report spending more time with their children 90% Fathers will report implementing at least one new self care habit into their life 90% Fathers will report a stable support network 90% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 5,000 11,000 10,000 Professional Fees 6,000 6,000 6,000 Operations 1,600 2,000 2,000 Supplies 500 2,000 2,000 Equipment Other: Food for Groups 1,500 4,120 3,000 Other: Fatherhood Events 5,000 14,000 12,000 Other: Socialization Events 0 3,000 Other: In-kind space and volunteers 2,000 1,000 Other: TOTAL 21,600 43,120 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): Member or members of the Council O Staff appointed by a member of the Council DI The Mayor • The Managing Director • The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: '] If no conflicts exist, check here. /// :.:( 7-,2 Signature of thorized on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. / / ? ? Signature of uthorized ,ie/on Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fathers will report improved understanding of their role as a father 90% Fathers will report improved relationship with the mother of their children 90% Fathers will report spending more time with their children 90% Fathers will report implementing at least one new self care habit into their life 90% Fathers will report a stable support network 90% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 10,000 Professional Fees 6,000 Operations 2,000 Supplies 2,000 Equipment Other: Food for Groups 3,000 Other: Bi Monthly Events 12,000 Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Family Support Services of West Hawaii Healthy Keiki 64 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Family Support Services of West Hawaii Program Name:Healthy Keiki Agency Director: Ray Wofford Phone No.:(808 )466 —2026 Contact Person: Stacy Brown Phone No.:(808 )443 —8530 Mailing Address: Address: 75-127 Lunapule Rd. Suite 11 Address: City,ST,Zip Kailua Kona, Hawaii, 96740 Facility Address: Address: 75-127 Lunapule Rd. Suite 11 Address: city,ST,zip Kailua Kona, Hawaii, 96740 Email Address: sbrown@fsswh.org Fax No.: (808 )323 —3393 Accountant/CPA: Phone No.:(808 ) 242 —5002 Firm (if applicable): Carbonaro CPA's & Management Group Mailing Address: Address: 1885 Main St. City,ST,Zip Wailuku, Hawaii 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) H Puna 0 Hamakua 0 North Kona ❑South Hilo 111 North Kohala ❑■ South Kona ❑ North Hilo Q South Kohala Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑■ Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name: Healthy Keiki 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0 $11 ,313 $14,250 2. Agency Mission Statement: Family Support Hawaii(FSH)began in 1979 as a grassroots organization providing family support in communities throughout West Hawaii. FSH incorporated as Family Support Services of West Hawaii in 1981 as a private, non-profit organization whose mission is"To Support Families and Communities in Providing Love and Care for our Children.This carefully chosen mission statement embodies two key elements:support for families and support for communities. The first element guides us in the direct work of supporting families,through our home visiting,occupational,speech,and physical therapies,infant and toddler child development centers, parent education/support programs,fatherhood initiative, breastfeeding support,and youth programs. The second element of our mission guides our work within communities to develop the capacity to provide a supportive environment for families and individuals. FSH works to achieve these elements through our community development activities,collaboration building,and advocacy work for a better quality of life for the people of Hawaii. Our mission statement encompasses the work that we do with dads,moms,grandparents, 'ohana caregivers,foster parents,infants,toddlers,youth,families experiencing homelessness,those who are disabled, disenfranchised,and those living in poverty. We strive daily to make a long lasting positive difference in their lives. Our community-based,culturally-responsive services are rooted in a philosophy of collaborative empowerment to build stronger,healthier families. 3. Program Description: Funding requested by the Family Support Hawaii Healthy Keiki Project will provide transportation supports for low-income families to attend scheduled medical,dental,and nutrition appointments in their community.The Healthy Keiki Project will be successful when families who were before unable to attend scheduled appointments will have met age-appropriate recommendations for their children's medical,dental,and nutrition needs. Developmentally, culturally,and linguistically appropriate health services support each child's optimal growth and school readiness. Early Head Start regulations require programs to identify the health(including oral health)and nutrition needs of each enrolled child and pregnant woman in the program and work with these families to secure transportation to these appointments. In the Family Support Hawaii Early Head Start program,99%of enrolled families are at or below the Federal Poverty Level and only about 30%of the enrolled families have ongoing, reliable sources of transportation.The COVID-19 pandemic has compounded challenges for low-income families in accessing modes of transportation in their communities. With job loss and reduction in work hours for many Early Head Start parents due to COVID-19,transportation needs have increased within the program. In addition to medical and health-related appointments,the program is proposing to include social service appointments to the project in order to better serve the needs of families.Social service appointments include visits to the Department of Human Services for SNAP(Supplemental Nutrition Assistance Program)benefits and financial assistance,appointments for housing assistance,and transportation to appointments to help families access employment,job training,or educational supports. If funded,the program will provide for an 18-hour/week staff member to provide transportation for families to the above-mentioned health and social service appointments. Fuel, repairs,and ongoing maintenance of agency vehicles is also included in the budget request. 4.Total Budget& Position Count: Total Program Budget: $24,000 Total Program Position Count: .45 Total Agency Budget: $2,687,800 Total Agency Position Count: 36 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii • Program Name: Healthy Keiki 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Office of Head Start-Funding for 12-hours/week for staff member to provide transportation. $10,255.00 County of Hawaii $24,000.00 TOTAL: Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The program will continue to identify funding sources to support the mission of this project. Family Support Hawaii utilizes the skills of a grant committee to identify funding sources which may be a match for this particular project.Other funding sources include the Hawaii Island Unitied Way,the Hawaii Community Foundation,and other private funds. In addition, FSH participates in several fundraising events each year(reduced this year due to the COVID-19 pandemic)which could supplement funding for this project. 7. Program Objectives Using County Nonprofit Grant Program Funds: Approximately 70%of the families served in the Early Head Start program do not have a reliable form of transportation, including 90%of those families with children with special needs.If awarded funding,the program will be able to provide transportation to a minimum of 57 families enrolled in the program. For these families,the peace of mind that comes along with getting their children to the doctor,dentist,WIC,and social services appointments is priceless.As good heath and good practices are closely linked to school readiness,it is imperative that completing medical,dental, nutrition,and social service visits be a priority for our program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Family Support Services of West Hawaii Program Name:Healthy Keiki 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are yaumeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Pregnant women will receive prenatal care as scheduled by a physician. 5 women x 6 prental visits=30 transports Children age 0-3 will receive well-baby visits as scheduled by a physician. 57 children x 2 well-baby visits=114 transports Children age 0-3 will receive preventative dental care as scheduled by a dentist. 57 children x 2 dental visits=114 transports WIC services will be accessed by those eligible as scheduled by WIC. 57 children x 2 WIC visits=114 transports EHS families will be transported to necessary social service appointments. 28 families x 2 appointments=56 transports Number of families to be served. A minimum of 57. Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $8,253 $13,520 $13,520 Professional Fees Operations $5,997 $10,480 $10,480 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $14,250 $24,000 $24,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Family Support Services of West Hawaii Program Name:Healthy Keiki 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council in Staff appointed by a member of the Council ® The Mayor fl The Managing Director [] The Director of Finance AssistantIn Corporation Counsel, or a The Corporation Counsel,the pDeputyCorporation oration p Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Di If no conflicts exist, check here. i / II , 27 January 2021 Signature of uthorized rs6n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Family Support Services of West Hawaii Program Name:Healthy Keiki 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 f ' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Family Support Services of West Hawaii Program Name:Healthy Keiki 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 27 January 2021 Signature Authorized Per-.n Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Family Support Services of West Hawaii Program Name:Healthy Keiki 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Pregnant women will receive prenatal care as scheduled by a physician. 30 transports Children age 0-3 will receive well-baby visits as scheduled by a physician. 114 transports Children age 0-3 will receive preventative dental care as scheduled by a dentist. 114 transports WIC services will be accessed by those eligible as scheduled by WIC. 114 transports EHS families will be transported to necessary social service appointments. 56 transports Number of families to be served. A minimum of 57 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $13,520 Professional Fees Operations $10,480 Supplies Equipment • Other: Other: Other: Other: Other: TOTAL $24,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The HAMAKUA Emergency Food Program 71 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:HAMAKUA Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 • City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑■ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) In Educational concerns ['Youth ❑■ Victims of Crimes ❑ Culture and the arts Q Aged ❑■ Victims of Health or Social Crises g Needs of the poor ❑■ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: HAMAKUA Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 2.Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawaii County. The Food Basket shall accomplish its mission by: 1)Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3) Facilitating community economic development that sustains and improves the island's food security. 4)Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment,organizational structure, and professional relationships with partners,donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The Hamakua Emergency Food Program serves the neediest residents in the Hamakua District through partner agencies, 'Ghana community food drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bag and pandemic Home Delivery distributions. A total of 46,498 individuals and/or families(duplicated)were served with over 360,180 pounds of food through their emergency food distributions in the Hamakua District in 2020. Additionally, a total of 26,149 pounds of emergency food was provided to 720 low income Seniors through The Food Basket's Kupuna Pantry program(USDA Commodity Supplemental Food Program) in the communities of Pa'auilo and Honoka'a. The Food Baskets Keiki Backpack program provided a total of 1,466 students with 3,253 pounds of nutritious easy-to-prepare foods over school breaks and holiday weekends. Total number of individuals served in Hamakua in 2020:48,684 individuals and/or families- 258%increase since 2019 Total number of pounds of emergency food distributed in Hamakua in 2020:389,582- 282%increase since 2019 4.Total Budget & Position Count: Total Program Budget: $218,607 Total Program Position Count: 0.72 FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: HAMAKUA Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $113,192 Contributions-corporate,foundations,and trusts $67,988 Federal grants $23,608 County of Hawaii $5,000 State contracts $2,591 All other revenue $6,228 TOTAL: $218,607 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations, 21%from federal, 1%from County, 3%from state contracts, 5%from earned revenue,and under 1%in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations (to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of Honoka'a, Laupahoehoe and Pa'auilo with at least 1 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve Hamakua rural communities. 3) Increasing the number of children served through our Keiki Backpack program in Hamakua schools. 4) Increase variety of supply for the emergency food distribution agencies in Hamakua, including fresh produce. 5) Increase the number of eligible Hamakua Seniors served with Kupuna Pantry and Senior Brown Bag. 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home Delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana Drops Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $41,172 $47,561 $5,000 Professional Fees $8,074 $16,267 Operations Supplies Equipment Other: Cost of food distributed $107,562 $135,597 Other: Non-personnel: supplies, phones, gas, shipping $10,991 $5,913 Other: Facility and equipment maintenance $9,091 $8,504 Other: Travel & meetings $1,254 $915 Other: Other expenses $4,704 $3,850 TOTAL $182,848 $218,607 $5,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Eli Member or members of the Council in Staff appointed by a member of the Council DI The Mayor QI The Managing Director The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. ExtuebYe i r&1 DYROI, o�,�o`�.I Signature of A horized Person (specify title) "Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: HAMAKUA Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to.submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 29,2021 Signa rtif Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:HAMAKUA Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages • $5,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $5,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc. The KA'IJ Emergency Food Program 72 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:KAU Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ■❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth ❑■ Victims of Crimes ❑ Culture and the arts ❑■ Aged ❑■ Victims of Health or Social Crises ❑� Needs of the poor ❑■ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: HAMAKUA Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 42 075.00 $20,463.00 $81 ,971 .00 2. Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawaii County. The Food Basket shall accomplish its mission by: 1)Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3) Facilitating community economic development that sustains and improves the island's food security. 4)Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment,organizational structure, and professional relationships with partners,donors and the community. 6)Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The Ka'u Emergency Food Program serves the neediest residents in the District of Ka'u and the communities of Volcano, Pahala, Na'alehu and Ocean View through partnering food pantries, elderly home meal service, our'Ohana Community food drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bag distribution. Emergency food distribution agencies include: Sacred Heart's Loaves and Fishes in Na'alehu; Friends Feeding Friends in Volcano;0 Ka'u Kakou at Pahala High School Gym;and Ka'u Food Pantry at St.Jude's Episcopalian Church in OceanView. A total of 31,072 individuals were served with over 443,411 pounds of food through these emergency food programs in the District of Kau in 2020. Additionally, a total of 60,578 pounds of emergency food was provided to 1,688 qualifying Seniors through The Food Basket's Kupuna Pantry/Senior Brown Bag program (USDA Commodity Supplemental Food Program). The Food Basket's Keiki Backpack program provided a total of 1,780 food insecure students at Naalehu elementary and Pahala elementary schools with 1,521 pounds of nutritious easy-to-prepare foods over school breaks and holiday weekends. Total number of people served in Ka'u in 2020: 34,520 individuals and/or families-109%increase since 2019 Total number of pounds of emergency food distributed in Ka'u in 2020: 505,510 pounds- 171%increase since 2019 4.Total Budget& Position Count: Total Program Budget: $400,236 Total Program Position Count: 1.31 FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: HAMAKUA Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $207,392 Contributions-corporate,foundations,and trusts $124,475 Federal grants $43,223 County of Hawaii $9,000 State contracts $4,743 All other revenue $11,402 TOTAL: $400,236 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations, 21%from federal, 1%from County,3%from state contracts, 5%from earned revenue, and under 1%in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Continued program service and C19 emergency food support to the communities of Volcano, Pahala, Na'alehu and Oceanview with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve Kau rural communities. 3) Increasing the number of children served through our Keiki Backpack program in Kai schools. 4) Increase variety of supply for the emergency food distribution agencies in Hamakua, including fresh produce. 5) Increase the number of eligible Kai Seniors served with Kupuna Pantry/Senior Brown Bag 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $75,379 $87,076 $9,000 Professional Fees $14,782 $29,782 Operations Supplies Equipment Other: Cost of food distributed $196,929 $248,258 Other: Non-personnel: supplies, phones, gas, shipping $20,123 $10,826 Other: Facility and equipment maintenace $16,644 $$15,569 Other: Travel & meetings $2,295 $1,676 Other: Other expenses $8,612 $7,049 TOTAL $334,764 $400,236 $9,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 0 Member or members of the Council IQ Staff appointed by a member of the Council fl The Mayor QI The Managing Director The Director of Finance 0 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I1 If no conflicts exist, check here. t l.MAAti V 1)4-6CA or G y aol a I Signat re of Auth rized Person (specify title) ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: HAMAKUA Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. , ,a / January 29, 2021 ja-- Signature ,f riz thoed Urson Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: HAMAKUA Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents & seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $9,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $9,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The NORTH HILO Emergency Food Program 73 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:NORTH HILO Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $3,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona Q North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth 0 Victims of Crimes ❑ Culture and the arts ❑■ Aged 0 Victims of Health or Social Crises ❑■ Needs of the poor ❑■ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: NORTH HILO Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 • 2.Agency Mission Statement: The mission of The Food Basket is to-end hunger in Hawaii County The Food Basket shall4.accomplish itsmission.by r 1)Providing cost effective and reliable services that supply food to those in need'and prevent food waste i 2)Coordinating food supply and distribution during emergencies 3)Facilitating community economic developmentfthat sustains and improves the islantl s food security 4)Developingjand implementing innovative programs to reduce hunger at itssource 5)FCultivating and maintaining a positive work;environment organizational structure and"professional relationships with partners,donors and the community 6)Establishing a reputation as a trusted and reliable organization among all stakeholders f 7)Achieving and sustaining positive financial operating results t {fF � , 3 3. Program Description: The North Hilo Emergency Food Distribution Program serves the neediest residents in the North Hilo District and the communities of Hakalau, Honomu, Pepe'ekeo and Papaikou through partner agency pantries, 'Ghana community food drops, Keiki Backpack and Kupuna Pantry and pandemic Home Delivery distributions. Pantries include: Immaculate Mary in Papaikou and First Assembly of God in Pepe'ekeo.A total of 2,546 individuals and/or families were served with over 26,141 pounds of food through food pantry distributions in the North Hilo District in 2020. Additionally, a total of 54,041 pounds of emergency food was provided to 1,488 low income Seniors through Kupuna Pantry distribution (USDA Commodity Supplemental Food Program)in North Hilo through sites in Pepe'ekeo and Papaikou. The Keiki Backpack program distribution provided a total of 468 pounds of nutritious easy-to-prepare foods to 197 food insecure students. Total number of people served in North Hilo in 2020: 4,231 individuals and/or families Total number of pounds of emergency food distributed in North Hilo in 2020:80,550#s 4.Total Budget & Position Count: Total Program Budget: $125,071 Total Program Position Count: 0.41 Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency. Name: Program Name: NORTH HILO Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $64,621 Contributions-corporate,foundations,and trusts $38,897 Federal grants $13,507 County of Hawaii $3,000 State contracts $1,482 All other revenue $3,563 TOTAL: $125,071 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations,21%from federal, 1%from County,3%from state contracts, 5%from earned revenue, and under 1% in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of North Hilo with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve North Hilo's rural communities. 3) Increasing the number of children served through our Keiki Backpack program in North Hilo schools. 4) Increase variety of supply for the emergency food distribution agencies in North Hilo, including fresh produce. 5) Increase the number of eligible North Hilo Seniors served with Kupuna Pantry and Senior Brown Bag. 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH HILO Emergency Food Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $23,555 $27,211 $3,000 Professional Fees $4,619 $9,307 Operations Supplies Equipment Other: Other: Cost of food distributed $61,539 $77,579 Other: Non-personnel: supplies, phones, gas, shipping $6,288 $3,383 Other: Facility and equipment maintenance $5,201 $4,865 Other: Travel & meetings $717 $524 Other: Insurance, computer tech, debt service $2,691 $2,203 TOTAL $104,610 $125,071 $3,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH HILO Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: • ;:.:... POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): flMember or members of the Council n Staff appointed by a member of the Council O The Mayor ® The Managing Director 01 The Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will resultin measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■ If no conflicts exist, check here. 1 1. v .e.1 r 1.-7-& zo2i Sign. `re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: NORTH HILO Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County-of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH HILO Emergency Food Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability" ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 29, 2021 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH HILO Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $3,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $3,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The NORTH KOHALA Emergency Food Program 74 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:NORTH KOHALA Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $1,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑� North Kohala ❑ South Kona ❑ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑� Youth Victims of Crimes ❑ Culture and the arts ❑� Aged E Victims of Health or Social Crises ❑■ Needs of the poor ❑■ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Food Basket, Inc. Program Name: NORTH KOHALA Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 2. Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawai'i County. The Food Basket shall accomplish its mission by: 1) Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3)Facilitating community economic development that sustains and improves the island's food security. 4)Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment,organizational structure,and professional relationships with partners, donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The North Kohala Emergency Food Distribution Program serves the neediest residents in the North Kohala District and the communities of Hawi and Kapa'au through partner agency food pantries, 'Ghana community food drops and Kupuna Pantry/Senior Brown Bag distributions. Sacred Heart Church food pantry in Hawi served a total of 18,962 individuals and/ or families with over 208,251 pounds of food through emergency food distributions in the North Kohala District in 2020. Additionally,a total of 6,537 pounds of emergency food was provided to 180 low income Seniors through Kupuna Pantry/ Senior Brown Bag distributions(USDA Commodity Supplemental Food Program) at Aina Kea Senior Center and and Aina Kea Senior Housing. Total number of people served in North Kohala District in 2020: 19,797 individuals and/or families-432%increase since 2019 Total number of pounds of emergency food distributed in North Kohala District in 2019: 215,322-a 934%increase since 2019 4.Total Budget & Position Count: Total Program Budget: $44,704 Total Program Position Count: 0.15 FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: NORTH KOHALA Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $23,170 Contributions-corporate,foundations, and trusts $13,903 Federal grants $4,828 County of Hawaii $1,000 State contracts $530 All other revenue $1,274 TOTAL: $44,704 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations, 21%from federal, 1%from County, 3%from state contracts, 5%from earned revenue, and under 1% in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and emergency food support to the communities of North Kohala with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve North Kohala's rural communities. 4) Increase variety of supply for the emergency food distribution agencies in North Kohala, including fresh produce. 5) Increase the number of eligible North Kohala Seniors served with Kupuna Pantry and senior brown bags. 6) Increase the number of struggling families served through community partnerships and The Food Baskets SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 Countyof Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KOHALA Emergency Food Program • 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $8,419 $9,726 $1,000 Professional Fees $1,651 $3,327 Operations Supplies Equipment Other: Cost of food distributed $21,996 $27,729 Other: Non-personnel: supplies, phones, gas, shipping $2,248 $1,209 Other: Facility and equipment maintenance $1,859 $1,739 Other: Travel & meetings $256 $187 Other: Insurance, computer tech, debt service $962 $787 TOTAL $37,391 $44,704 $1,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KOHALA Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): CO Member or members of the Council in Staff appointed by a member of the Council ▪ The Mayor ▪ The Managing Director - • The Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: []■ If no conflicts exist, check here. 411Exe ve_ Direef or- 01/9‘61(c1.0 a1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KOHALA Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KOHALA Emergency Food Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 29, 2021 Signatu e of Autho ed Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KOHALA Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for monthly distribution Once per mo. Serve additional at risk seniors Additional 10% Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional 20% Increase variety of food offered (including locally produced) Additional TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $1,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippini Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $1,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The NORTH KONA Emergency Food Program 75 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:NORTH KONA Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 l Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 ) 934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION'CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑■ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth Q Victims of Crimes ❑ Culture and the arts ❑■ Aged ❑� Victims of Health or Social Crises ❑� Needs of the poor Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: NORTH KONA Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 2.Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawaii County. The Food Basket shall accomplish its mission by: 1)Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3)Facilitating community economic development that sustains and improves the island's food security. 4) Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment, organizational structure,and professional relationships with partners,donors and the community. 6)Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The North Kona Emergency Food Distribution Program served the neediest residents in the North Kona District and the communities of Kailua Kona, Kea'ahou, Kealakehe and Holualoa and through partner agency pantries, 'Ohana community food drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bag distributions. Partner agencies include: Kona BISAC; Kona Kids Outreach; Better Tomorrow;Child and Family; Ulu Wini; Lokahi Treatment Center; Mental Health Kokua; Kona Adult Day Care; Hope Services Kona; Kona HIV/Aids;West Hawai'i Salvation Army;Bridge House; Meet and Eat;Amazing Grace Ministries;Hawai'i Sober Living; Bible First Mission and St. Michael's.A total of 75,610 individuals and families were served with 593,493 pounds of food. 900 seniors were served with 32,686 pounds of food through Kupuna Pantry and Senior Brown Bag. A total of 78,710 individuals and/or families were served in 2020 Over 628,059 pounds of food was distributed in the North Kona District in 2020-and increase of 42%individuals served and 190%increase in food distributed since 2019 4.Total Budget & Position Count: Total Program Budget: $465,580 Total Program Position Count: 1.53 FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: NORTH KONA Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $241,721 Contributions-corporate,foundations,and trusts $144,797 Federal grants $50,280 County of Hawaii $10,000 State contracts $5,518 All other revenue $13,264 TOTAL: $465,580 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations, 21%from federal, 1%from County, 3%from state contracts, 5%from earned revenue,and under 1% in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of North Kohala with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve North Kohala's rural communities. 3) Increasing the number of children served through our Keiki Backpack program in North Kohala schools 4) Increase variety of supply for the emergency food distribution agencies in North Kohala, including fresh produce. 5) Increase the number of eligible North Kohala Seniors served with Kupuna Pantry and Senior Brown Bag. 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 'I County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KONA Emergency Food Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for monthly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $87,686 $101,293 $10,000 Professional Fees $17,195 $34,644 Operations Supplies Equipment Other: Cost of food distributed $229,080 '$288,789 Other: Non-personnel: supplies, phones, gas, shipping $23,408 $12,593 Other: Facility and equipment maintenance $19,361 $18,111 Other: Travel & meetings $2,670 $1,949 Other: Insurance, computer tech, debt service $10,018 $8,200 TOTAL $389,418 $465,580 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name:NORTH KONA Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council In Staff appointed by a member of the Council O The Mayor ®I The Managing Director co The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. EWAAjive, Dire,c"ix b JAVA oaI Signat r of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: NORTH KONA Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:NORTH KONA Emergency Food Program sa. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 29, 2021 1/ se Signatu a Authoriz-d Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: NORTH KONA Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The PUNA Emergency Food Program 76 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:PUNA Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth D Victims of Crimes ❑ Culture and the arts ❑■ Aged ❑■ Victims of Health or Social Crises ❑■ Needs of the poor ❑■ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: PUNA Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 2.Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawaii County. The Food Basket shall accomplish its mission by: 1)Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3) Facilitating community economic development that sustains and improves the island's food security. 4)Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment, organizational structure, and professional relationships with partners,donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The Puna Emergency Food Distribution Program serves the neediest residents in the Puna District and the communities of Kea'au, Pahoa, Kalapana, Kurtistown, Mountain View, Glenwood plus the many subdivisions. Emergency food is distributed through partner agencies,'Ghana community food drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bags and Home Delivery distributions. Partner agencies include: Neighborhood Place of Puna; Kurtistown Assembly of God food pantry and soup kitchen;Teen Challenge of the Hawaiian Island;St.Theresa;Sacred Heart Pahoa; Malu Aina; Kalapana Mauna Kea;Grass Roots Church;Pahoa pantry;Ola'a First Hawaiian Church; Bodacious Women;Sure Foundation; Pahoa Community soup kitchen;Orchidland Neighbors; HPP Neighborhood Watch. A total of 97,302 individuals and/or families were served with over 927,690 pounds of food through partner agencies in the Puna District in 2020. Additionally, a total of 99,365 pounds of emergency food was provided to 2,736 low income Seniors through the Kupuna Pantry/Senior Brown Bag distribution (USDA Commodity Supplemental Food Program)in Puna through sites in Pahoa and Kea'au . The Keiki Backpack distribution provided a total of 23,202 pounds of nutritious food to 7,631 food insecure students in the Puna districts through multiple events. Total number of people served in Puna in 2020: 107,669 individuals and/or families-an increase of 42%since 2019 Total number of pounds of emergency food distributed in Puna in 2020: 1,050,257 pounds-an increase of 98%since 2019 4.Total Budget& Position Count: Total Program Budget: $1,140,971 Total Program Position Count: 3.75 FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: PUNA Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $591,879 Contributions-corporate,foundations,and trusts $354,846 Federal grants $123,219 County of Hawaii $25,000 State contracts $13,523 All other revenue 32,205 TOTAL: $1,140,971 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations, 21%from federal, 1%from County, 3%from state contracts,5%from earned revenue, and under 1% in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of Puna with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve Puna's rural communities. 3) Increasing the number of children served through our Keiki Backpack program in Puna schools 4) Increase variety of supply for the emergency food distribution agencies in Puna, including fresh local produce. 5) Increase the number of eligible Puna Seniors served with Kupuna Pantry/Senior Brown Bags. 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: PUNA Emergency Food Program I 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana Drops Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $214,888 $248,233 $25,000 Professional Fees $42,139 $84,901 Operations Supplies Equipment Other: Cost of food distributed $561,394 $707,720 Other: Non-personnel: supplies, phones, gas, shipping $57,366 $30,862 Other: Facility and equipment maintenance $47,447 $44,384 Other: Travel & meetings $6,543 $4,777 Other: Insurance, computer tech, debt service $24,551 $20,094 TOTAL $954,328 $1,140,971 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: PUNA Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 0 Member or members of the Council in Staff appointed by a member of the Council QI The Mayor ▪ The Managing Director ▪ The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 1] If no conflicts exist, check here. j e u 4I lit D r- /A.ci p.Da Signatu of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: PUNA Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 ' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:PUNA Emergency Food Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. c_. ‘ . fie,...._ January 29, 2021 Signa ure of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 ' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: PUNA Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana Drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $25,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The SOUTH HILO Emergency Food Program 77 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH HILO Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $42,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑ Hamakua ❑ North Kona ['South Hilo ❑ North Kohala ['South Kona ❑ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑� Youth EI Victims of Crimes ❑ Culture and the arts g Aged ❑■ Victims of Health or Social Crises O Needs of the poor 0 Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH HILO Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 2. Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawaii County. The Food Basket shall accomplish its mission by: 1) Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2) Coordinating food supply and distribution during emergencies. 3)Facilitating community economic development that sustains and improves the island's food security. 4)Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment,organizational structure, and professional relationships with partners,donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. • 3. Program Description: • The South Hilo Emergency Food Distribution Program served the neediest residents through 33 partner agencies, 'Ghana community food drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bag and Home Delivery distributions. Our partners include:BISAC;Young Life Hawai'i;Lighthouse; HCEOC;Grace Baptist:Living Waters; Hope Services; Freedom to Choose; Hawaii Island HIV/AIDS foundation;Goodwill; Kinoole Baptist church;YMCA;Hale Kipa; Mental Health Kokua;Christ Lutheran church; Kihei Pua;PonoHawaii; Kings Fellowship; Hongwanji Mission; Malia Puka 0 Kalani;Salvation Army Pantry;Salvation Army Meals; Under His Wings;Child and Family services;Ke ala Pono;Clem Akina community soup kitchen; Panaewa community alliance;Kaapalana; Hawai'i Community College pantry;Thy Word Ministries; Boy Scouts;SNAP Outreach;TFB emergency food boxes; Kapiolani, Keaukaha and Hilo Union Elementary schools;Tutu&Me Traveling Preschool, South Hilo Sites& Home-Visiting Program; Vet Center Hilo;Legal Aid Society of Hawaii;United Healthcare;St.Joseph's Storehouse. In 2020 over 1,085,369 pounds were distributed to over 244,365 individuals or families. 4,248 food-insecure seniors were served with over 154,278 pounds of food.3,544 food insecure school aged children were served with 3,029 pounds of nutritious food through multiple distributions. In 2020 a total of 252,157 individuals and/or families were served-an increase of 39%since 2019 In 2020 over 1,242,676 pounds of food was distributed in the South Hilo District-an increase of 40%since 2019 4.Total Budget& Position Count: Total Program Budget: $1,911,577 Total Program Position Count: 6.28FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH HILO Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $991,515 Contributions-corporate,foundations,and trusts $594,506 Federal grants $206,441 County of Hawaii $42,000 State contracts $22,656 All other revenue $54,458 TOTAL: $1,911,576 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations,21%from federal, 1%from County, 3%from state contracts, 5%from earned revenue,and under 1% in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of South Hilo with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve South Hilo's rural communities. 3) Increasing the number of children served through our Keiki Backpack program in South Hilo schools 4) Increase variety of supply for the emergency food distribution agencies in South Hilo, including fresh local produce. 5) Increase the number of eligible South Hilo Seniors served with Kupuna Pantry/Senior Brown Bags. 6) Increase the number of struggling families.served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH HILO Emergency Food Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $360,021 $415,888 $42,000 Professional Fees $70,600 $142,243 Operations Supplies Equipment Other: Cost of food distributed 940,557 $1,185,710 Other: Non-personnel: supplies, phones, gas, shipping 96,110 $51,705 Other: Facility and equipment maintenance $79,492 $74,361 Other: Travel & meetings $10,962 $8,004 Other: Insurance, computer tech, debt service $41,132 $33,666 TOTAL $1,598,874 $1,911,576 $42,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 • County of flawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name:SOUTH HILO Emergency Food Program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ri Staff appointed by a member of the Council ▪ The Mayor O The Managing Director O The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: �■ If no conflicts exist, check here. /f/' ,/,; eke,cu-ti-vt . Nrecdr 0 Vacip0A1 r Signat re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name:SOUTH HILO Emergency Food Program is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH HILO Emergency Food Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govtin-nonprofit-grant-forrns/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01/29/20 Signature oi:A ' horized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH HILO Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $42,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $42,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The SOUTH KOHALA Emergency Food Program 78 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH KOHALA Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑■ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ■❑Victims of Crimes ❑ Culture and the arts 0 Aged 0 Victims of Health or Social Crises ❑■ Needs of the poor ❑■ Physical/Emotional Disabilities El Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH KOHALA Emergency Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 • $42,075.00 $20,463.00 $81 ,971 .00 2.Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawai'i County. The Food Basket shall accomplish its mission by: 1) Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3)Facilitating community economic development that sustains and improves the island's food security. 4)Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment,organizational structure, and professional relationships with partners,donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The South Kohala Emergency Food Distribution Program served the neediest residents in the South Kohala District and the communities of Waimea and Waikoloa through the partner agencies of Annunciation Church and Kokua Christian Ministries and through'Ghana community food drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bag and Home Delivery distributions. A total of 457,787 pounds of emergency food was provided to 45,302 individuals through partner agencies in the South Kohala District in 2020. 516 seniors were served with over 18,740 pounds of food through Kupuna Pantry/Senior Brown Bag(USDA Commodity Supplemental Food Program)programs. The Keiki Backpack distribution provided a total of 1,407 pounds of nutritious, easy-to-prepare foods over school breaks and holiday weekends to food was distributed to 1,646 food insecure students. In 2020 a total of 47,464 individuals and/or families were served-a 166%increase since 2019 In 2020 over 477,934 pounds of food was distributed in South Kohala-a 944%increase since 2019 4.Total Budget & Position Count: Total Program Budget: $98,205 Total Program Position Count: 0.32 FTE Total Agency Budget: $6,680,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH KOHALA Emergency Food Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $51,095 Contributions-corporate,foundations,and trusts $30,542 Federal grants $10,606 County of Hawaii $2,000 State contracts $1,164 All other revenue $2,798 TOTAL: $98,205 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38%of our agency revenues come from individual donors. Additional revenue sources include: 31%from organizations,21%from federal, 1%from County,3%from state contracts,5%from earned revenue,and under 1%in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year,including our annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of South Kohala with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Home Delivery program to serve South Kohala ' s rural communities. 3) Increasing the number of children served through our Keiki Backpack program in South Kohala schools 4) Increase variety of supply for the emergency food distribution agencies in South Kohala,including fresh local produce. 5) Increase the number of eligible South Kohala Seniors served with Kupuna Pantry/Senior Brown Bags. 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH KOHALA Emergency Food Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they hove participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered(including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $18,496 $21,366 $2,000 Professional Fees $3,627 $7,308 • Operations Supplies Equipment Other: Cost of food distributed $48,320 $60,914 Other: Non-personnel - supplies, phones, gas, shipping $4,938 $2,656 Other: Facility and equipment maintenance $4,084 $2,000 Other: Travel & meetings $563 $1,164 Other: Insurance, computer tech, debt service $2,113 $2,798 TOTAL $82,141 $98,205 $2,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH KOHALA Emergency Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council IO Staff appointed by a member of the Council OI The Mayor OI The Managing Director OI The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. / • LY€-GtAtl klt. D i t-E GT V i✓ �� / a t� Signature • uthori d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH KOHALA Emergency Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH KOHALA Emergency Food Program ii.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1)/U1/ Signature o'"Authorized -erson Date . Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH KOHALA Emergency Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippinl Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,dE Other: TOTAL $2,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Food Basket, Inc.,The SOUTH KONA Emergency Food Program 79 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name:SOUTH KONA EMERGENCY FOOD PROGRAM Agency Director: Kristin Frost Albrecht Phone No.:(808 )933 —6030 Contact Person: Phone No.:( ) — Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 I Kailua-Kona, HI 96740 Email Address: Kristin@hawaiifoodbasket.org Fax No.: (808 )934 —0701 Accountant/CPA: Ann Fukuhara Phone No.:(808 ) 961 —5532 Firm (if applicable): Mailing Address: Address: P.O. Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $3,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑■ South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns *Youth ['Victims of Crimes ❑ Culture and the arts El Aged ■❑Victims of Health or Social Crises ❑■ Needs of the poor Q Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH KONA EMERGENCY FOOD PROGRAM 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $42,075.00 $20,463.00 $81 ,971 .00 2. Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawai'i County. The Food Basket shall accomplish its mission by: 1)Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3) Facilitating community economic development that sustains and improves the island's food security. 4) Developing and implementing innovative programs to reduce hunger at its source. 5) Cultivating and maintaining a positive work environment, organizational structure,and professional relationships with partners,donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The South Kona Emergency Food Distribution Program served the neediest residents in the South Kona District and the communities of Kona, Kealakekua, Captain Cook and Honaunau through partner agencies, 'Ghana and/or Mobile Food Pantry community drops, Keiki Backpack and Kupuna Pantry/Senior Brown Bag distributions in 2020. Partner agencies included:St. Benedict's; Kona Gospel Chapel; Pukaana Church; Holo Hole Ministries and Kona Adult Day Care.A total of 50,875 pounds was provided to 5,177 individuals or families through partner agencies in the South Kona District in 2020. 516 seniors were served with over 18,740 pounds of food through Kupuna Pantry/Senior Brown Bag (USDA Commodity Supplemental Food Program)programs. The Keiki Backpack distribution provided a total of 5,010 pounds of nutritious easy-to-prepare food distributed to 2,000 food insecure students. In 2020 a total of 7,693 individuals and/or families were served-an increase of 46%since 2019 In 2020 74,625 pounds of food was distributed in South Kona-a 46%increase since 2019 4.Total Budget & Position Count: Total Program Budget: $109,150 Total Program Position Count: 0.36 FTE Total Agency Budget: $6,890,000 Total Agency Position Count: 25.50 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawaii'i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH KOHALA Emergency Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions-individual $56,013 Contributions-corporate,foundations, and trusts $33,946 Federal grants $11,788 County of Hawaii $3,000 State contracts $1,294 All other revenue $3,110 TOTAL: $109,150 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: About 38% of our agency revenues come from individual donors. Additional revenue sources include: '31%from organizations, 21%from federal, 1%from County, 3%from state contracts, 5%from earned revenue, and under 1% in special events. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year, including our annual Feed-a-thon and numerous food drives that yield monetary contributions. We contract with the Williams Grant Writing firm to bolster our general operations (to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Continued program service and C19 emergency food support to the communities of South Kona with at least 12 food drops per community in 2021. 2) Maximizing community food and partnership through the development of our Mobile Market and Food Pantry(DA BUS) program to serve South Kona-s rural communities. 3) Increasing the number of children served through our Keiki Backpack program in South Kona schools 4) Increase variety of supply for the emergency food distribution agencies in South Kona, including fresh local produce. 5) Increase the number of eligible South Kona Seniors served with Kupuna Pantry/Senior Brown Bags. 6) Increase the number of struggling families served through community partnerships and The Food Basket's SNAP Outreach team. EXHIBIT A • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH KONA EMERGENCY FOOD PROGRAM 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide food to partner agencies for weekly distribution Once per month per agency Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once a month Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $20,557 $23,747 $3,000 Professional Fees $4,031 $8,122 Operations Supplies Equipment Other: Cost of food distributed $53,705 $67,704 Other: Non-personnel - supplies, phones, gas, shipping $5,488 $2,952 Other: Facility and equipment maintenance $4,539 $4,246 Other: Travel & meetings $626 $457 Other: Insurance, computer tech, debt service $2,349 $1,922 TOTAL $91,295 $109,150 $3,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH KONA EMERGENCY FOOD PROGRAM 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council • Staff appointed by a member of the Council DI The Mayor ▪ The Managing Director ▪ The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. .17 ,a) bet cA c e. .D vI r e+ r /acl/ku,at Signat e of u orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 The Food Basket, Inc. Agency Name: Program Name: SOUTH KONA EMERGENCY FOOD PROGRAM 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH KONA EMERGENCY FOOD PROGRAM 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 29, 2021 Signature'of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:The Food Basket, Inc. Program Name: SOUTH KONA EMERGENCY FOOD PROGRAM 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food to partner agencies for weekly distribution Once per mo. Serve additional at risk residents and seniors Home delivery Increase number of children being served KBP once/mo. Increase number of struggling families being served Additional Increase variety of food offered (including locally produced) Ohana drops TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $3,000 Professional Fees Operations Supplies Equipment Other: Supplies,phones,gas,shippin! Other: Facility and equipment Main Other: Travel, meetings Other: Insurance, computer tech,de Other: TOTAL $3,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Friends of Big Island Drug Court, Inc. (FOBIDC) Friends of BigDrug Island Court . 80 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name:Friends of Big Island Drug Court Agency Director: Jessica Caravalho Phone No.:(808 ) 217 —2425 Contact Person: Grayson Hashida Phone No.:(808 )443 —2201 Mailing Address: Address: P.O. Box 6914 Address: City,sr,zip Hilo, HI 96720 Facility Address: Address: Address: City,ST,Zip Email Address: grayson.k.hashida@courts.hawaii.gov Fax No.: (808 ) 443 —2222 Accountant/CPA: N/A ) Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of,Request for County Nonprofit Grant Program Funds: $10,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna Q■ Hamakua North Kona Q South Hilo 0 North Kohala Q■ South Kona ❑� North Hilo Q South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑� Youth ❑■ Victims of Crimes Ei Culture and the arts E1 Aged ❑■ Victims of Health or Social Crises ❑� Needs of the poor ❑� Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 So So So 2. Agency Mission Statement: The Big Island Drug Court and Big Island Veterans Treatment Court address community problems related to substance abuse and mental health by providing'timely and effective treatment for justice-involved youth,adults and veterans across the entire County.The programs enhance collaboration among key parties in the justice system, including the judicial system, law enforcement,substance abuse treatment agencies, health care providers,social services, mental health interests,and the public. As a result, Drug Court and Veterans Treatment Court programs reduce recidivism:91%of Big Island Drug Court program graduates.have successfully avoided felony convictions in the three years after graduation. Drug and Veterans Treatment Courts reduce jail admissions,'reduce societal costs,and promote public safety and family reconciliation. These programs have costs, hovIever. Friends of Big Island Drug Court(FOBIDC)raises funds to cover support services and supplies critical in helping participants of Drug Court and Veterans Treatment Court overcome barriers and successfully complete the program;'avoid recidivism,and sustainably return to their families and community. 3. Program Description: Started in 2002,Big Island Drug Court is based at the Court Houses in Hilo(Hale Kaulike)and Kona(Keahuolu).As of mid-2020, BIDC has served a total of 468 adult clients,of which 227(48.5%)have successfully graduated. The Big Island Drug Court combines drug treatment with mental health and medical follow up,prompt incentives and sanctions, sober support meetings,frequent court interaction,drug testing, and intensive probation monitoring. In addition, all Drug Court graduates have access to reliable transportation,have or attain a GED of Competency-based high school diploma, made payment towards their restitutions and fines,and have improved family relationships.These are achieved through a team approach, led by the judge,which includes the Prosecutor's Office,the Public Defender, probation, substance abuse treatment, law enforcement,and other treatment providers. Since 2014,the Big Island Veterans Treatment Court is modeled after the Drug Court program and serves non-violent veterans in Hilo and Kona. Big Island Veterans Treatment Court participants receive additional care and services specific to veterans, including assistance with upgrading their military or Veterans Administration status and the support of a Veteran Mentor. Currently,the maximum capacity is 140 adult clients for Big Island Drug Court and 24 veteran participants for Big Island Veterans Treatment Court. 4.Total Budget& Position Count: Total Program Budget: 22,000.00 Total Program Position Count: See Attachment Total Agency Budget: 22,000.00 Total Agency Position Count: See Attachment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate HI County Nonprofit Grant(anticipated) 10,000.00 Donations(anticipated) 6,000.00 Atherton Family Foundation(anticipated) 3,000.00 HI County Contingency Relief Fund(anticipated) 3,000.00 • TOTAL: 22,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In the past, FOBIDC has relied on donations and occasional County grants, including a County Nonprofit Grant in 2016 and County Contingency Relief Grants in 2018 and 2019.As COVID-19 exacerbated existing hardships for our participants,including by reducinghousing,and employment opportunities as well as public transportation options,the FOBIDC Board committed to applying to foundations and to launching a website to communicate more broadly its mission and activities. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Encourage successful completion of Program activities by providing participation incentives such as gift cards to stores and restaurants. 2)Meet basic life necessities for those recently released from custody, including obtaining identification, clothing, and personal hygiene supplies. 3)Support participants in securing safe and appropriate housing by providing a grant towards a portion of the deposit. 4)Support participants in obtaining employment by providing funds towards education and job training. 5)Remove barriers to obtaining housing,education and employment by providing transportation(bus and taxi coupons) and funds for childcare. 6)Celebrate program graduates and promote positive participant identity by organizing events such as graduation and program presence in community events EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) See Attachment f ' Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees . 1,000.00 3,000.00 0 • Operations ti 869.00 2,400.00 0 Supplies 3,706.00 6,850.00 6,850.00 Equipment 200.00 300.00 0 Other: Housing Grant (prior year grant returned) 300.00 3,000.00 1,000.00 Other: Education & Job Training 400.00 3,550.00 250.00 Other: Graduations, Special Events, T-shirts 1,084.00 1,900.00 1,900.00 Other: Employment Support (tools,etc.) 0 1,000.00 0 Other: TOTAL 7,559.00 22,000.00 10,000.00 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council l ❑ Staff appointed by a member of the Council in The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑' If no conflicts exist, check here. 6\42 JA" \b-i)OAA Ci-C--1)`4eck—Vv-i to\VA-24? \ ignatu - o thor' ed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit:Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and.ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications'will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in,the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in atimely manner will impact the evaluation of your acrency_'s future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Ot 7k \W.) 1 Signatu e of Authorized Person Date ?°c-c-ti&iesir\\- Y t ra a (/"i' ��'�it/, v .5,),(\t Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of Big Island Drug Court, Inc. (FOBIDC) Program Name: Friends of Big Island Drug Court 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result See Attachment. i I ' � 1 1 TABLE II: FY 21-22 Council PROGRAM'EXPENDITURES Grant Request Award Salary and Wages ; 0 Professional Fees ' 0 Operations 0 Supplies 6,850.00 Equipment 0 Other: Housing Grant 1,000.00 Other: Education & Job Training 250.00 Other: Graduations, Special Evert' 1,900.00 Other: Support tool Employment 0 PP ( � Other: TOTAL 10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Nonprofit Grant Application FY24.21-22 Agency Name F,nends of Big is}and Drug Court, Inc (FQBIDC} �- �� � Program Name. Friends at Big Island Drug Courte ATTACHMENTS 4. Total Position Count: o Total Program Position Count: 0* *Program is administered through partner agency, Big Island Drug Court Coordinator, Mr. Grayson Hashida. • Total Agency Position Count: 10* *.10 volunteer members of the FOBIDC Board of Directors. 8. TABLE I : ric N Yo 'z c .. S' V .� r§ 'r✓ '" L+i z 4 zr'j`z - yAm a. "„' ,a sn 1 r !` a. a `�' �i ?_;:: s .L�f i 3 a - kx 3i s '"4 �a rgel � � ' ��4 �� � � P�ro:MJram�Performan�,�e�O�ttcomes a=�}` �- 0� `i...z. .� �a ' Increase motivation`to avoid drugs and to engage in positive 200 gift card incentives behavior(such as completing drug treatment) by providing incentives in the form of gift cards. Increase clients'abilities to successfully start their recovery 50 hygiene kits program by providing hygiene kits and helping them obtain 5 new government IDs some form of government ID. Increase opportunity for Drug &Veterans Treatment Court 4 housing grants of$250 clients to access affordable housing by providing grants each towards housing deposits. For clients who do not have access to their own 400 bus tickets & 50 taxi transportation, increase attendance at court, substance abuse coupons and mental health treatment and sober support meetings by providing bus and taxi coupons. Increase clients' ability to secure employment by providing $200 in clothing and grants to assist with educational and job training goals, childcare assistance work-appropriate clothing, and/or childcare. $250 to support educational/job training goals Celebrate achievement of participants who have successfully 3 graduation events completed Drug &Veterans Treatment Court programs by organizing graduation events to which family and friends can be invited 1 • County of Hawaici Nonprofit Grant Application FY2O21-22 Agency Name: Friends of BIsland Drug Court, Inc (=FFOBIDC) Program"N me: Friends of Big Island Drug Court 12. COUNCIL AWARD WORKSHEET " Program Performance Measures Applicant Council dProposed y Projected Results Pro�ected'Results } Increase motivation to avoid drugs and to 200 gift card engage in positive behavior(such as 1 incentives completing drug treatment) by providing incentives in the form of gift cards. i Increase clientp' abilities to successfully start 50 hygiene kits their recovery program by providing hygiene kits 5 new government and helping them obtain some form of IDs government ID{. Increase opportunity for Drug &Veterans 4 housing grants of Treatment Court clients to access affordable $250 each housing by providing grants towards housing deposits. For clients who do not have access to their own 400 bus tickets & 50 transportation, increase attendance at court, taxi coupons substance abuse and mental health treatment and sober support meetings by providing bus and taxi coupons. Increase clients' ability to secure employment $200 in clothing and by providing grants to assist with educational childcare assistance and job training goals, work-appropriate clothing, and/or childcare. $250 to support educational/job training goals Celebrate achievement of participants who 3 graduation events have successfully completed Drug & Veterans Treatment Court programs by organizing graduation events to which family and friends can be invited 2 Friends of the Children's Justice Center of East Hawaii Special Needs, Enhancement, Support, Education &Training 84 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training Agency Director: Robin Benedict Phone No.:(808 )935 —8755 Contact Person: Robin Benedict Phone No.:(808 )935 —8755 Mailing Address: Address: P.O. Box 6908 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1290 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: fcjceh@fcjceh.org Fax No.: (n/a ) — Accountant/CPA: Evelyn Paiva Phone No.:(808 ) 969. —9023 Firm (if applicable): EMP Business Services Mailing Address: Address: 474 Kalanikoa St. City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ■❑ Puna 0 Hamakua ❑ North Kona E South Hilo ❑ North Kohala ❑South Kona 0 North Hilo ❑South Kohala EJ Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth Ej Victims of Crimes 0 Culture and the arts ❑Aged 0 Victims of Health or Social Crises L1 Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 • County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education &Training 1. Prior Year Award of County Nonprofit Grant Program Funds: • FY 18-19 FY 19-20 FY 20-21 $11 ,750 $11 ,938 $11 ,300 2.Agency Mission Statement: In partnership with the Children ' s Justice Center,we exist to meet the needs of abused and neglected children of East Hawaii. We focus our efforts on helping child victims with resources and hope,while striving to educate the public about child abuse. 3. Program Description: The Program serves children between the ages of 0-18,who are documented victims of abuse,or are witnesses to crime, residing in East Hawaii,filling requests for special needs and enhancements(i.e.clothing, hygiene items, beds, bedding, transportation,school supplies,intercession activities,tutoring, holiday and birthday gifts,Winners Camp,sports,dance, arts,and music). The Program provides Center support to the Children's Justice Center of East Hawaii, by providing for resources to help reduce trauma and ensure the safety and comfort of the children that come to the Center for interviews. The Friends maintain the Center's safe, child-friendly and homelike atmosphere,with toys,books,stuffed animals, games,snacks, and a gently used children's clothes closet.Through education and prevention,the Friends educates the community regarding child abuse issues.The Program plans events for the public, and maintains and updates the Friends website, promoting child abuse awareness and prevention.The Program sponsors training,by supporting the attendance of professionals at seminars and conferences,to learn state-of-the-art interviewing techniques to enhance and refine their overall skills. 4.Total Budget& Position Count: Total Program Budget: $178,470 Total Program Position Count: Total Agency Budget: $203,460 Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Children's Justice Center of East Hawaii Pro ram Name: Special Needs, Enhancement, Support, Education &Training 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii 11,300 Donations and Miscellaneous 17,396 Fundraising • 20,000 Special Events-Phantom,Charity Walk,etc. 25,764. Foundations:Teresa Hughes,and Victoria&Bradley Geist 100,000 Hawaii Island United Way 5,000 Corporate donations/grants 24,000 TOTAL: 203,460 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends do not collect fees for any of our services. We are continuously researching for additional grant funding, striving to increase donations for our Phantom mail-out non-event fundraiser,Gala dinner event,and our Masquerade event fundraiser.Because of challenges presented by the COVID-19 pandemic,we have recently suspended our social gathering events,and focused our efforts on a mail-out campaign and social media. • 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide funds for emergency needs(clothing,hygiene Items, bedding,car seats,baby needs, health related needs, etc.) and enhancements(sports-equipment,fees and registration, dance,drama,music, art,school supplies,school pictures, tutoring,intercession activities, ground and air transportation, holiday and birthday gifts,prom and graduation expenses, etc.).Assist police,social workers, and other professionals in keeping up to date with the latest investigative techniques, sensitivity training,forensics and knowledge of resources,by helping to support their attendance at training workshops and seminars. Provide privacy, comfort and safety for children and family members who come to the Center,by maintaining its warm environment. Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education &Training 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Fill"Special Need&Enhancement"Requests 1,200 requests Serve child victims of abuse and or neglect 600 children Volunteers will donate hours to help children receive services 6 volunteers Ongoing Center support for the Children's Justice Center 300 children Abused&neglected children will receive holiday&birthday gifts 250 children Participation in community education&training events 5 events Attach additional pages as necessary. • 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 60,809 59,416 --- Professional Fees --- --- --- Operations 27,211 22,140 1,130 Supplies 1,254 744 744 Equipment 1,694 240 --- Other: Special Needs Requests 99,449 116,300 5,650 Other: CJC Center Support 1,019 960 960 Other: Education & Prevention, Community Outreach 4,150 2,700 2,156 Other: Volunteer Expenses 544 300 --- Other: Liability Insurance for County of Hawaii 591 660 660 TOTAL 196,721 203,460 11,300 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Marcia Prose POSITION: President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): 0 Member or members of the Council •; Staff appointed by a member of the Council ® The Mayor ® The Managing Director 0 The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. /- M7 O/ 40 424 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION • FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jill Jacunski POSITION:Vice-President and Treasurer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council II Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Mr If no conflicts exist, check here. VP IN(d✓a,'.- f --334-c4.1 Signature of Authorized Person (specify title) Date • EXHIBIT A NONPROFIT GRANT APPLICATION - FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documentsare complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION • FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at htt1://www.hawaiicounty.gov fn-n/ onprofit-grant-forms(on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ' 0 '1 V _ ' 4..A... 0/ 1446/.2%624 . Signature of Authorized Person Date nl cR-c yej--iK.e".. Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fill "Special Need & Enhancement" Requests 1,200 requests Serve child victims of abuse and or neglect 600 children Volunteers will donate hours to help children receive services 6 volunteers Ongoing Center support for the Children's Justice Center 300 children Abused & neglected children will receive holiday & birthday gifts 250 children Participation in community education & training events 5 events TABLE II: FY 21-22 . Council PROGRAM EXPENDITURES Grant Request. Award Salary and Wages --- Professional Fees --- Operations 1,130 Supplies 744 Equipment Other: Special Needs Requests 5,650 Other: CJC Center Support 960 Other: Education & Prev/Outreach 2,156 Other: Volunteer Expense --- Other: Liability Insurance C of H 660 TOTAL 11,300 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 ATTACHMENT Friends of the Children's Justice Center of East Hawaii Special Needs, Enhancement, Support, Education &Training Program P. O. Box 6908, Hilo,HI 96720 Are4vic,Mi Bus: (808)985-8755 E-Mail: fcjcehfcjceh.org A www.fcjcEastlawaii.org Program Description: Founded in 1990, the Friends of the Children's Justice Center, also known as the "Friends", is a private nonprofit organization, with the primary goal of enhancing and protecting the physical and psychological well-being of abused and neglected children. The Friends work in partnership with the Children's Justice Center(CJC), a State of Hawaii Judiciary Program. The CJC provides a safe, neutral homelike atmosphere, where children can be interviewed regarding allegations of abuse, particularly sexual abuse. This Children's Justice Center facilitates and coordinates the system's response to victims of child abuse, to reduce their trauma, through a multi-disciplinary teem approach, which involves police, social workers, prosecutors, guardians ad litem, medical professionals, advocates, and others. The Friends support the CJC primarily by helping to provide resources for direct services and programs, for child victims and their families, which are not available through any other public or private source. The Friends accept requests for funding from State and private agencies working with child abuse victims, such as Child Protective Services, Child and Family Services, Hawaii Behavioral Health, Catholic Charities, Parents Inc., and other agencies. The Friends serve children between the ages of 0-18, and up to 21 who attend high school and are in voluntary foster care, and who are victims of abuse (sexual, physical, emotional, mental abuse or neglect, or are witnesses to crime) residing in East Hawaii. This includes North Hilo, South Hilo, Hamakua, Puna and parts of Ka'u. We serve children with active or documented cases of abuse and neglect. The Special Needs and Enhancement Program is designed to help child victims develop positive self-worth. The Friends provide resources for needs that are not covered by any other public or private source. Funds are used to provide basic essentials (i.e. clothing, diapers, toiletries), special needs (i.e. air/ground transportation, school supplies, correspondence courses) and enhancement support (i.e. sports, music, dance lessons, art, and tutoring). The Friends also fill requests for holiday and birthday gifts for children not covered by other programs. Center Support: The Friends provide resources to help reduce trauma and ensure the safety and comfort of the children that come to the Children's Justice Center for interviews. The Friends maintain the Center's safe, child-friendly and homelike atmosphere with toys, games and snacks. The community supports our efforts with donations of clothing, for our clothes closet, and stuffed animals. The Friends also help maintain the Center's appearance with repairs and refurbishing when needed. Wage of 2 ATTACHMENT 1,:'..,-'.....-.:_--,jFriends of the Children's Justice Center of East Hawaii - Special Needs, Enhancement, Support, Education &Training Program �� P. 0. Box 6908, Hilo,HI 96720 `( Bus: (808)985-8755 E-Mail: fcjcehfcjceh.or°g A www.fcjcEastlawaii.org The Prevention and Education Program is designed to educate the community regarding child abuse issues. This program plans events for the public, promoting awareness and prevention of child abuse. The Training Program helps to support the attendance of various professionals (i.e. social workers, police & therapists) at seminars and conferences to learn state-of-the-art interviewing techniques and refine their overall skills. These professionals work with child victims and their families. Training opportunities enhance the quality of services and prevents victims from being re-traumatized by possible difficiencies in the system's response to the allegations of abuse. Program Objectives: 1) Provide funds for clothing, hygiene items, bed/mattress and other necessities for children in emergency or relative foster placement. 2) Provide funds for tutoring, correspondence courses or summer school to allow a child to graduate or progress to the next grade level. 3) Provide funds for ground or air transportation for children to participate in family vacations/reunions, attend school or team events, or to see medical specialists. 4) Provide funds for children to participate in supervised spring and winter intersession activities, or summer camps. 5) Pay for fees, equipment and supplies needed for extracurricular activities i.e.: sports, music, art, drama, dancing lessons, etc. 6) Provide funds for holiday or birthday gifts when a child would otherwise not receive a gift. 7) Provide funds (or gift cards) for gas, to families on a limited budget so children may be able to attend treatment programs. 8) Provide funds for diapers, car seats and other baby supplies for infants who are victims of abuse and neglect. 9) Pay for event fees, prom dresses, senior pictures, yearbooks, etc., to give a student a chance to participate in school functions. 10) Assist police, social workers, and other professionals in keeping up to date with the latest investigative techniques, sensitivity training, forensics and knowledge of resources by helping to sponsor their attendance at training workshops and seminars. 11) Provide privacy, comfort and safety for children and family members who come to the Center, by maintaining its warm environment. 12) Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. 2IPage of 2 . Friends of the Palace Theater Annual Musical 85 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Palace Theater Program Name:Annual Musical Agency Director: Phillips Payson Phone No.:(808 ) 934 —7120 Contact Person: Phillips Payson Phone No.:(808 ) 934 —7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: phillips.payson@hilopalace.com Fax No.: ( ) — Accountant/CPA: Bob Nutt Phone No.:(808) 963 —6160 Firm (if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street City,sr,zip Hilo Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 22,000 Geographical Areas To Be Served: (One or more can be checked) E Puna ❑ Hamakua D North Kona g South Hilo ❑ North Kohala ❑South Kona Q North Hilo ❑South Kohala 0 Ka.'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns E Youth ❑Victims of Crimes ❑� Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Annual Musical 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 4550 5036 4775 2. Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize, restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo,and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists, local and international filmmakers,and for community-based,multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational,multi-ethnic dialogue and discourse. The core values of the organization strive to provide stewardship and preservation while adapting to the changing times and realities of Hawaii's commiunity and culture. 3. Program Description: The Annual Musical is the signature event and biggest fundraiser of the year for the Palace Theater.Proceeds from this event provide operational funding to the Palace Theater for several months each year. Each year for the last 20 years,the Palace Theater has presented a professional-quality Broadway Musical Theater production lasting over 3 weekends. Staff,Board members and volunteers dedicate months on preparation and rehearsal for the production.Excitement about the event increases over these months,as word spreads by word of mouth. This popular event attracts the residents of East Hawaii,along with visitors from the mainland,who frequently make their vacation plans around the Annual Musical. In 2019, Larry Reitzer,a talented Hollywood Scriptwriter and Director was welcomed to the Board of Directors. Larry has served as Company Manager on the Broadway and national tours of Les Miserables and Phantom of the Opera,and has spent over 20 years in writing, producing and working in television on such shows as Spin City and Ugly Betty. He will be joined by local veteran choreographer,Michael Misita,.who has worked on many of the Palace's musical productions. The Palace Theater is an excellent venue for this kind of production,and the event provides an opportunity for local artists to highlight the vibrant arts community in East Hawaii. Due to covid-related restrictions,this years'event will take place later in the year than usual,and will feature both a live audience(at a reduced capacity)and live streaming on the Palace website and social media. 4.Total Budget& Position Count: Total Program Budget: 34,000 Total Program Position Count: 1 FTE Total Agency Budget: 462,064 Total Agency Position Count: 4 FT; 10+ PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Annual Musical 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source . Estimate Box office 10000 Cafe,Gift shop 2000 County of Hawaii 22000 TOTAL: 34,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater has historically supported all of its programs through eight primary sources: Box office revenue,Cafe revenue,donations,major sponsors,grants, rentals,volunteers,and in-kind donations-all of which will be leveraged to support the program again this year. Due to Covid-related restrictions,the Annual Musical will be presented later in the year,once a vaccine has been in distribution for a few months,to ensure the maximum attendance possible. Also,staff are currently experimenting with Virtual/Live Streamed programming to remain engaged with Palace patrons in the interim. These new branding and marketing strategies are already increasing awareness of the Palace Theater,and will round out the cumulative results of fundraising to make this program sustainable into the future. County funding to support Directors'fees,musicians,and technical staff is a key aspect of the program,as a monetary commitment to the Directors and performers will help lay the framework and encourage other donors to support this important program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of this request is to ensure the continuity of this major fundraising event to which the local community and visitors to the island look forward with enthusiasm.This signature event has historically contributed to annual operations,as well as showcasing the Palace Theater as a excellent venue for large theatrical productions. This is vital,since there is a tremendous amount of talent in East Hawaii,but not many places to showcase it. The Musical at the Palace Theater provides an opportunity for artists to highlight the vitality of the arts scene in Hilo. Due to the Covid-related closure and subsequent restrictions on audience size,there has not been an opportunity to build up a reserve of funds to plan and execute the show in the normal time-frame. In addition,it is anticipated that capacity will be reduced well into 2021,meaning that box office income will be greatly reduced. Not having this upfront capital means that all costs of the musical,including licensing, marketing,wardrobe and sets will have to be paid out of very limited operating funds. Annual continuity of this popular signature event is critical;this request is for County Nonprofit Grant Program funds to sustain the program until full capacity and programming can resume. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Annual Musical 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Increased Revenue from ticket sales +20% Increased audience engagement from targeted marketing strategies +20% Increased usage of the theater as a venue for large productions +5% Increased efficacy of virtual platforms for theater events +100% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 2500 2500 2500 Professional Fees 5500 5500 3000 Operations 3000 3000 Supplies 1500 1500 Equipment Other: Sound Man/Equipment 5000 5000 3500 Other: Musical Rights 3500 3500 3500 Other: Foundational Live Streaming Equipment 5500 5500 Other: Sets, props and Costumes 2500 2500 1500 Other: Marketing 5000 5000 2500 TOTAL 28500 34000 22000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Annual Musical 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: pJ If no conflicts exist, check here. Q—c) 'x ' 6 .icor 2. /2.1 Signature of Authorized P- o specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Annual Musical 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate,prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Annual Musical 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 11 zt Signature of Authorize• ' - so Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Annual Musical 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increased revenue from tiocket sales +20% Increased audience participation from targeted marketing +20% Increased usage of theater as a venue for large events +5% Increased efficacy of virtual platforms for theater events 100% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 2500 Professional Fees 3000 Operations Supplies Equipment Other: Sound Man/Equipment 3500 Other: Musical Rights 3500 Other: Foundational Live Streamt 5500 Other: Sets, props, and costumes 1500 Other: Marketing 2500 TOTAL 22,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Friends of the Palace Theater Hawaiian Roots Festival of Talent 86 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Palace Theater Program Name:Hawaiian Roots Festival of Talent Agency Director: Phillips Payson Phone No.:(808 ) 934 —7120 Contact Person: Phillips Payson Phone No.:(808 ) 934 —7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: phillips.payson@hilopalace.com Fax No.: (808 ) 934 —7120 Accountant/CPA: Bob Nutt Phone No.:(808) 963--6160 Firm (if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street City,ST,Zip Hilo Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 15000 Geographical Areas To Be Served: (One or more can be checked) g Puna D Hamakua ❑ North Kona g South Hilo ❑ North Kohala ❑South Kona g North Hilo ❑South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes O Culture and the arts g Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 4550 4673 6125 2.Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize,restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo, and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists, local and international filmmakers,and for community-based, multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational,multi-ethnic dialogue and discourse. The core values of the organization strive to provide stewardship and preservation while adapting to the changing times and realities of Hawaii's commiunity and culture. 3. Program Description: The Hawaiian Islands comprise a diverse collection of many different ethnicities and age groups.Traditionally, Hawaiians have used music and performance to define themselves and to celebrate"aloha'aina",or love of the land,and to record their history,daily lives,feelings and beliefs. This program will consist of several performances,each highlighting a different variety of song,musical instrument and/or performance. Examples of what will be showcased include slack key guitar,ukulele,hula dancing,taiko,traditional dance,and falsetta singing. All age groups will be represented in this mix,supporting our understanding that arts and culture plays an essential role in promoting sustainable social and economic development for future generations. A newly developed virtual platform has allowed the presentation of"Live from the Empty Palace",a series of pre-recorded performances that are released weekly on the Palace website. This innovation has greatly helped the theater retain the engagement of its patrons during the Covid-19-mandated closures and reduction in capacity.The Hawaiian Roots program will build on this,and will combine the virtual performances with ticketed events to incorporate all the elements of cultural and historical interest-the experiential,emotional,and visual. It is expected that as the theater is able to open at increased capacity,and continue to present more and more authentic Hawaiian performances, it will become self-sustaining. 4.Total Budget& Position Count: Total Program Budget: 26,000 Total Program Position Count: 1 FTE Total Agency Budget: 462,064 Total Agency Position Count: 4 FT; 10+PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Box office 9000 Cafe/Gift shop 2000 County of Hawaii 15000 TOTAL: 26000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources: Box office revenue,Cafe revenue, donations, major sponsors,grants, rentals,volunteers,and in-kind donations-all of which will be leveraged to support this program. Also,staff are currently experimenting with Virtual/Live Streamed programming to remain engaged with Palace patrons in the interim. "Live from the Empty Palace"has become extremely popular. These new branding and marketing strategies are already increasing awareness of the Palace Theater,and will round out the cumulative results of fundraising to make this program sustainable into the future. 7. Program Objectives Using County Nonprofit Grant Program Funds: Hawaii is known for its authentic Hawaiian style. Many fine and famous Hawaiian musicians and performers were born in and around Hilo, or elsewhere on the Big Island.The arts,particularly the performing arts,play a large part here,and set Hilo apart from many other island communities. There is a wealth of talent in the area,and the Palace Theater is dedicated to preserving this for veteran performers,as well as for the up and coming arts students who have been inspired top follow in their footsteps. The primary objective of this program is to actively encourage and support native Hawaiian culture,art,artists,and practitioners. Specifically,the program seeks to: -recognize and encourage local artists,and to highlight and showcase the immense amount of local talent in East Hawaii -provide opportunities to the public, both local residents and visitors,to experience and appreciate Hawaiian music -encourage and develop target audiences for Hawaiian music -serve as a vehicle for passing on the oral records of Hawaiian history,culture,and lifestyle -promote sustainable cultural tourism by providing authentic, place-based experiences. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of performers participating +10 Number of new patrons +25 Percdent of positive feedback about the program and request to continue it 90% Increased efficacy of virtual programming for theater events 100% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 3500 1000 Professional Fees 5000 Operations 1500 1500 750 Supplies 2400 1500 Equipment Other: Foundational IivestreamNideo hosting equipment 5500 2750 Other: Sound Engineer and equipment 3600 3500 2500 Other: Marketing and Advertising 5000 5000 3000 Other: Artist fees 10000 8000 6000 Other: TOTAL 31000 26000 15000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0� If no conflicts exist, check here. 9$tru ;ve-«moo✓ I Z' 2 Signature of Au orize Per •n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I,(we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. > > 1/24, 1 Signature of Authori d P son Date ExeCu1 -fir Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of preformers participating in program +10 Number of new patrons engaged +25 Percent of positive feedback and requests to continue program 90% efficacy of virtual elements 100% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations 750 Supplies Equipment Other: Foundational Livestream/M j 2750 Other: Sound Engineer and Equird 2500 Other: Marketing and Advertising 3000 Other: Artist fees 6000 Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Friends of the Palace Theater Youth Theater Program 87 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Friends of the Palace Theater Program Name:Youth Theater Program Agency Director: Phillips Payson Phone No.:(808 ) 934 —7120 Contact Person: Phillips Payson Phone No.:(808 ) 934 —7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: phillips.payson@hilopalace.com Fax No.: (808 ) 934 —7120 Accountant/CPA: Bob Nutt Phone No.:(808) 963--6160 Firm (if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street City,ST,Zip Hilo Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL.OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 15000 Geographical Areas To Be Served: (One or more can be checked) ❑� Puna ❑ Hamakua ❑ North Kona E South Hilo ❑ North Kohala ❑South Kona g North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑� Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor D Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater g Y Program Name: Youth Theater Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 3125 4471 5325 2. Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize,restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo,and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists, local and international filmmakers,and for community-based,multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational, multi-ethnic dialogue and discourse. The core values of the organization strive to provide stewardship and preservation while adapting to the changing times and realities of Hawaii's commiunity and culture. 3. Program Description: The success of the Palace Theater's professional-style musicals geared to a younger audience and starring youth in the cast led, in 2019,to the incorporation of a full youth-oriented theater program.A full-scale musical-theater production of a beloved theater classic,such as Beauty and the Beast,will be presented each spring. This program, overseen and directed by Larry Reitzer,a Board member with over 20 years experience touring,writing, producing and workingon Broadway, involves acting,singing, and stagecraft and will feature upto 100 young 9 9dancing 9 Y 9 performers per show. Initially intended to mitigate the challenges of first having to close,then reduce capacity,of the theater due to COVID-19,a Virtual Lecture Series and a Reading Series have been incorporated into the program. These have become so popular that they will be permanent elements of the program. The guest lecturers are all entertainment industry professionals from the world of Broadway,film and television. The lectures are followed by information and assistance with resume writing,where to search for a job,how to sell yourself, and how to put together a promotional acting reel.The Reading Series allows young actors to practice their art on stage with a small audience(in-person and via ZOOM)and have the chance to get feedback from a professional director and producer. The script is read,followed by a discussion of the play,the playwright,and whether it would be a candidate for a full production at the theater. 0 4.Total Budget& Position Count: Total Program Budget: 25,500 Total Program Position Count: 1 FTE Total Agency Budget: 462,064 Total Agency Position Count: 4 FT; 10+PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater a Program Name: Youth Theater Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Box office 9000 Cafe/Gift shop 1500 County of Hawaii 15000 TOTAL: 25500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources: Box office revenue,Cafe revenue, donations,major sponsors,grants, rentals,volunteers,and in-kind donations-all of which will be leveraged to support this program. Due to Covid-related restrictions,the Youth Musical will be presented later in the year,once a vaccine has been in distribution for a few months,to ensure the maximum attendance possible. Also,staff are currently experimenting with Virtual/Live Streamed programming to remain engaged with Palace patrons in the interim. The virtual Lecture and Reading Series are extremely popular.These new branding and marketing strategies are already increasing awareness of the Palace Theater,and will round out the cumulative results of fundraising to make this program sustainable into the future. New branding and marketing strategies are already increasing awareness of the Palace Theater.Continuous advertising to target audiences,assessing customer satisfaction,and adding a new show and performers annually will round out the cumulative results of fundraising to make this program sustainable into the future. 7. Program Objectives Using County Nonprofit Grant Program Funds: East Hawaii is a diverse community with many different age groups, income levels,and ethnicities. An emerging interest is the development of arts programming for youth. The intent of this program is to expose young artists to every aspect of the arts industry,and to prepare them with knowledge,awareness,confidence and inspiration to follow their passion and their dreams. Today,the prevailing wisdom is that an understanding of arts and culture plays an essential role in promoting sustainable social and economic development for future generations.Promoting creativity,collaborative effort,and motivations is therefore a priority to finding solutions to today's challenges. (Culture and Youth Development, United Nations,2017) The Youth Theater Program that is being developed and refined by the Palace Theater creates new opportunities for a broader engagement of youth and their parents,Specifically,the program will provide opportunities for youth to develop and share their gifts and talents in a"hands-on"experiential and exploratory learning environment,and will encourage a sense of pride and self-esteem. We foresee that by inspiring and encouraging the building of capacity in acting,dancing and singing as well as in the technical disciplines like lighting and sound,we will assure that we have the local talent necessary to sustain a robust and professional theater scene in Hilo for generations to come. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 . Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of youth parfticipating in program 100+ Number of new patrons(parents,family members,teachers)engaged as audience 200+ Percdent of positive feedback about the program and request to continue it 90% Increased efficacy of virtual programming for theater events 100% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 800 Professional Fees 7000 5000 3000 Operations 1000 1000 Supplies 3000 3000 1500 Equipment Other: Foundational livestreamNideo hosting equipment 5500 5500 Other: sets costumes and props 2000 2000 Other: sound engineer and equipment 5000 5000 3000 Other: Advertising and marketing 4000 4000 2000 Other: scholarships 6000 TOTAL 28,800 25500 15000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Youth Theater Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: DI If no conflicts exist, check here. c-Th eyeatve..., - i & Ivi Signature of Authoriz Pers 2._... cs ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Youth Theater Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Youth Theater Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. - - 1 /14 Signature of Authorl:.i•erson Date &PeCUPV Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Friends of the Palace Theater Program Name:Youth Theater Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Youth participating in program 100+ Number of new patrons, (parents, family members, teachers) engaged 200 Percent of positive feedback and requests to continue program 90% efficacy of virtual elements 100% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 3000 Operations Supplies 1500 Equipment Other: Foundational Livestream/\ 5500 Other: Sets costumes and props Other: Sound Engineer and Equilj 3000 Other: Advertising and marketing 2000 Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 F=uli Life Adult Day Health Community Learning and Art Center 88 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Full Life Program Name:Adult Day Health Learning and Art Center Agency Director: Jim Kilgore Phone No.:(808 ) 322 —9333 Contact Person: Jim Kilgore Phone No.:(808 )322 —9333 Mailing Address: Address: 75-6082 Ali'i Drive, Suite#8 Address: City,sr,Zip Kailua Kona, HI 96740 Facility Address: Address: 75-6129 Ali'i Drive #2,3,4 Address: City,ST,Zip Kailua Kona, HI 96740 Email Address: jim@fulllifehawaii.org Fax No.: (808 ) 322 —9334 Accountant/CPA: Ann Fukuhara Phone No.:(808) 961 —5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street, Suite 102 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑® North Kona ❑South Hilo ❑ North Kohala E South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑� Culture and the arts ❑Aged ❑Victims of Health or Social Crises g Needs of the poor g Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Adult Day Health Learning and Art Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 7994 (program) 19,738 (total) 7,720 (program) 18,171 (total) 6875 (program) 14,750 (total) 2.Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: The Learning Center is an adult day health program for adults with developmental disabilities.Social skills, recreational pursuits,and independent living skills are encouraged,developed, and shared. Participants are empowered to thrive. Desired results include measurable improvements in individual independence and other skill building that leads to increased community integration.This year Full Life is relocating our Adult Day Health program to Alii Gardens Marketplace to be a truly inclusive program that benefits both community members and visitors.We are partnering with Donkey Mill Art Center and other local nonprofits as well as community businesses and individual volunteers to make this a successful endeavor.This program will advance physical,social,and economic inclusion of people with developmental disabilities. Fill Life celebrates creativity;the artistic endeavors of participants with developmental disabilities are valued. The Full Life Adult Day Health Learning and Art Center Program will assist Full Life in providing transportation from participants homes to the Learning and Art Center and back to their homes.This year the program will also assist participants who are interested to consign their art work and crafts with participants earning 100%of the revenue.Other local artists will be able to help sustain the program by consigning their art at the marketplace for a percentage.The program's overall goal is to foster relationships and collaboration with others in order to achieve our program objectives for individuals served. We see this is a viable alternative model giving people with developmental disabilities a purposeful and meaningful day where, like the ocean,they move forward together with their community. 4.Total Budget& Position Count: Total Program Budget: 170,000 Total Program Position Count: 10 Total Agency Budget: 3,800,000 Total Agency Position Count: 87 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Adult Day Health Learning and Art Center 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Nonprofit Grant-Adult Day Health Learning and Art Center 10,000 State of Hawaii Department of Health,Developmental Disabilities Division 135,000 Fundraising and other Grants 15,000 Public Consignment fees 10,000 TOTAL: 170,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Full Life plans to increase enrollment and participation at the program post COVID-19 Pandemic.The space will be transformed into an inclusive art space with community engagement offering multiple opportunities to collaborate and seek funding and volunteers from the community.We also will work with local high school special education programs and offer use of our space for job training and other skills.We hope some of those students will enroll with Full Life when they graduate. Increased enrollment results in increased revenues through the State of Hawaii Developmental Disabilities Division. During the pandemic we are able to maintain revenues with virtual programming and tele-health. Full Life also plans to market the new location to other community artists and makers who want to consign their work.We hope that eventually the revenue from that effort will help sustain the program. We continue to use the results from the County of Hawai'i Nonprofit Grant to build a greater case for additional grant funding and private donations. Full Life will leverage our new community connections with the program to develop individual donations and grants. 7. Program Objectives Using County Nonprofit Grant Program Funds: The intended outcome is to improve the participants'social skills,develop and retain social-valued roles,independently use community resources,develop leisure interests and hobbies,exercise civil rights and self-advocacy,and develop art interests and begin to earn an income with their art. 1.Full Life plans to serve up to 12 individuals 2. Full Life will recruit 5 community members to volunteer and support the retail operations 3. Participants will attend at least 4 community based activities per week totaling 200 community visits to facilitate inclusion and community participation 4.We will maintain relationships with current community partners and identify 5 additional community partnerships. 5.Transform the Learning Center into an Art Center and Marketplace opening up use to the general public and high school special education departments. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Adult Day Health Learning and Art Center 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of Clients Served Satisfied with the program 12 Number of community based activities that participants find valuable to ongoing community involvement 200 Number of community partners that participants can use as network after the program 10 Number of community members benefiting from the new Art Center and Market measured as sales or visitors 1000 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 36592 85000 6000 Professional Fees 0 6000 0 Operations 34787 40000 1000 Supplies 5112 12000 1000 Equipment 0 12000 0 Other: Transportation and Vehicle Maintenance ., 4933 15000 2000 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 81,424*Projected 170,000 10000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Adult Day Health Learning and Art Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council in Staff appointed by a member of the Council ▪ The Mayor co The Managing Director fl The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 171 If no conflicts exist, check here. � C ,04 - 1/20/2021 Si:iature of Authorize;/person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Adult Day Health Learning and Art Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority or records pertinent to the grant, contract, or to examine and inspect any facility, equipment, property, program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Adult Day Health Learning and Art Center ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.Rov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials,insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. (, / r 0..t 1/20/2021 l; A ure of Authorized Pe orn Date xecutive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Adult Day Health Learning and Art Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Clients Served Satisfied with the program 12 Number of community based activities that participants find valuable to ongoing community involvement 200 Number of community partners that participants can use as network after the program 10 Number of community members benefiting from the new Art Center and Market measured as sales or visitors 1000 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 6000 Professional Fees 0 Operations 1000 Supplies 1000 Equipment 0 Other: Transportation and VehiclEh 2000 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 10000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Fuld Life Associated Costs for Self-Determined Living 89 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Full Life Program Name:Associated Costs for Self-Determined Living Agency Director: Jim Kilgore Phone No.:(808 ) 322 —9333 Contact Person: Jim Kilgore Phone No.:(808 )322 —9333 Mailing Address: Address: 75-6082 Ali'i Drive, Suite#8 Address: City,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: 120 Keawe St. Ste. 201 Address: City,ST,zip Hilo, HI 96720 Email Address: jim@fulllifehawaii.org Fax No.: (808 ) 322 —9334 Accountant/CPA: Ann Fukuhara Phone No.:(808) 961 —5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street, Suite 102 City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $6000 Geographical Areas To Be Served: (One or more can be checked) g Puna Q Hamakua ❑■ North Kona 0 South Hilo ❑. North Kohala g South Kona ❑� North Hilo 0 South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) D Educational concerns J Youth ❑Victims of Crimes O Culture and the arts ❑Aged ❑Victims of Health or Social Crises ED Needs of the poor g Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 5,869 (program) 19,738 (total) 4,893(program) 18,171 (total) 3,265(program) 14,750 (total) 2.Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: Full Life believes that every person,regardless of ability,deserves to lead a happy,fulfilled,and self-determined life based on their own individual strengths,preferences,and dreams. We believe that families,communities,and workplaces are made stronger when we embrace all of our members.Our goal is for each and every one of us to be empowered to create, live,and share a full life. With funding from Associated Costs for Self-Determined Living, people with disabilities will have opportunities to participate in virtual activities and events,explore employment,access public activities,improve and maintain a safe and comfortable standard of living,and evolve through educational opportunities and technology.Associated Costs are expenses related to Personal Assistance and Community Learning Services that may pay for costs required for a Direct Support Worker to accompany a participant to an activity and/or purchase items/services that support a person with a disability to reach goals for independence. Associated Costs include: technology and Internet to participate in virtual events and activities;items or scholarships that allow participants to take part in job readiness programs;items or activities that support development of social valued roles; participants with financial obstacles can access public activities which maximizes community integration; replacement of old or upgrading needed equipment and supplies allow participants to feel comfortable and safe in their home;and purchase services for self-care(not covered by insurance). Associated costs ensures our participants keep moving toward a thriving full life. All associated costs will be related to the participants individualized goals written in their individual service plans. 4.Total Budget& Position Count: Total Program Budget: 14,000 Total Program Position Count: 55 Total Agency Budget: 3,800,000 Total Agency Position Count: 87 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Nonprofit Grant-Adult Day Health Learning and Art Center 6000 Fundraising and other grant initiatives 7000 Individual Donations 1000 TOTAL: 14000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Full Life continues to build programs with the support and funding from the County of Hawai'i to leverage State of Hawai'i contracts to serve people with developmental disabilities and their families.The State of Hawai'i contracts allows Full Life to build capacity to provide innovative service delivery such as offering associated costs for self-determined living to participants in State of Hawai'i Waiver programs. Full Life continues to access additional grant funding and private donations.We recently hired a part time public relations expert and grant writer.We have been successful with social media fundraising initiatives to pay for larger associated cost expenses for certain participants requiring more significant resources to reach self-determined goals.We will continue requesting contributions,writing grants,and researching other funding opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: With County Nonprofit Grant Program funds, Full Life's Associated Costs for Self-Determined Living Program objectives include: 1. Provide Associated Cost Funds to 30 participants with Developmental Disabilities based on goals in their individual service plans.The use of the funds will be monitored by a program coordinator and an associated costs committee. 2.Support 15 participants to pursue and/or explore self-employment. 3. Develop capacity to expand associated costs to at least 50%of Full Life participants by January,2023. 4. Increase outcomes of self-determination through monitoring the impact of associated costs on pursuing individual goals. 5. Participants using associated costs to support inclusion will increase their participation in community related activities by 25% EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How ore youmeasuring what happens for the Participants after they hove participated in your program?Describe,be specific.) Survey participants on how items or activities purchased with associated costs benefited self-determination Target 25 people reporting increased self-determination Number of participants who maintain or obtain successful employment with assistance from associated costs Target 15 participants maintain or obtain employment Survey the participants to identify if associated costs improved their access to community inclusion Target 20 participants reporting improved community inclusion Survey participants to to identify if associated costs improved their ability to live independently Target 20 participants reporting improved independent living Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 0 0 0 Supplies 2263 4500 1900 Equipment 2829 4500 1900 Other: Community activities and classes 2488 4000 1500 Other: meals, snacks, beverages for social activities 566 1000 700 Other: 0 Other: 0 Other: 0 TOTAL 8146 projected 14000 6000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Associated Costs for Self-Determined Living 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council 0 The Mayor ❑I The Managing Director f] The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: J If no conflicts exist, check here. �• �. Ore 1/20/2021 :nature of Authoriz Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Associated Costs for Self-Determined Living 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Associated Costs for Self-Determined Living 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.Rov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/20/2021 Signa ure of Authorized Pers'( Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name:Associated Costs for Self-Determined Living 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Survey participants on how items or activities purchased with associated costs benefited self-determination =5pe9lerepo,pnehnr:easee,;elwelermuneb» Number of participants who maintain or obtain successful employment with assistance from associated costs15panropanvmanlamorobt&,empIoyn,enl Survey the participants to identify if associated costs improved their access to community inclusion 20parAdpanla reporting Improved community Survey participants to to identify if associated costs improved their ability to live independently =g paNepanta reporAng improved mdepender TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 1900 Equipment 1900 Other: Community activities and qlj 1500 Other: Meals/snacks for social achy 700 Other: Other: Other: TOTAL 6000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 FuIO Life Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists 90 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Full Life Program Name:Empowering Creativity- Pua Na Pua and Abled Hawaii Artists Agency Director: Jim Kilgore Phone No.:(808 ) 322 —9333 Contact Person: Jim Kilgore Phone No.:(808 ) 322 —9333 Mailing Address: Address: 75-6082 Ali'i Drive, Suite#8 Address: City,sr,Zip Kailua Kona, HI 96740 Facility Address: Address: 120 Keawe St. Ste. 201 Address: City,ST,ZIP Hilo, HI 96720 Email Address: jim@fulllifehawaii.org Fax No.: (808 ) 322 —9334 Accountant/CPA: Ann Fukuhara Phone No.:(808) 961 —5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street, Suite 102 City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Hamakua 0 North Kona E South Hilo 0 North Kohala E South Kona ■❑ North Hilo 0 South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes O Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑� Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-.22 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawai'i Artists 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 5875 (program) 19,738 (total) 5558 (program) 18,171 (total) 4250 (program) 14,750 (total) 2.Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: Full Life's Empowering Creativity program provides people with developmental disabilities and other disabilities opportunities for enrichment in the arts by empowering them to develop and exhibit artistic talents.This program has been made possible and expanded through support by Hawai'i County and other local partners. Art festivals are an important component of this program.We hope that festivals will resume in 2021-2022.However,we have successfully demonstrated virtual festivals during the pandemic and are prepared to pivot if there are pandemic related barriers.The two festivals are Pua Na Pua and Abled Hawai'i Artists.Pua Na Pua is an inclusive art festival that includes art workshops culminating in a festival in partnership with Donkey Mill Art Center,Lanihau Shopping Center,and other community collaborators.Abled Hawaii Artists is an annual Hawai'i Island community art festival showcasing the artistic work of people with disabilities in East Hawaii.Abled Hawaii Artists(AHA)is the largest celebration of the Americans with Disabilities Act in Hawai'i.AHA was formed by a group of advocates and self-advocates in an effort to raise awareness of the disabled community and the arts,celebrating both as an integral part of out vibrant culture in Hawai'i.AHA also partners with Live Aloha Art Festival in Hilo featuring virtual performance art,short-films,and arts. Full Life is requesting funding to continue expanding art classes and cultivate interest for people with developmental disabilities to participate in AHA and Pua Na Pua. Art has no limitations.Art is an instrument of communication and expression.Art culture and diversity can be experienced by everyone.Our goal is for the community to embrace and celebrate the talents of people with disabilities and to encourage awareness and inclusion of people with perceived differences in the art community. 4.Total Budget& Position Count: Total Program Budget: 35,000 Total Program Position Count: 11 Total Agency Budget: 3,800,000 Total Agency Position Count: 87 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai'i Nonprofit Grant-Adult Day Health Learning and Art Center 9,000 State of Hawaii Department of Health,Developmental Disabilities Division 9,500 Silent Auction Donations 5,000 Vendor Fees 1,500 Individual Contributions and Donations 3,000 Other Grant Funding 7,000 TOTAL: 35,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Full Life continues to partner with other non profit organizations and community members to increase revenues and support the Empowering Creativity Program. For example,Donkey Mill Art Center raises funds for the program through individual contributions and silent auctions.We now have an ongoing venue for sales of items at the Full Life Art Center at Alii Gardens Marketplace in addition to the Donkey Mill Gift Shop. Full Life received other funding to expand programming including a donation from Alexander and Baldwin(donated to Donkey Mill Art Center)and a partnership with the Resiliency Hubs. Individual donations continue to increase every year through social media fundraising. The State of Hawaii Developmental Disabilities Division continues to increase referrals to Full Life to support participants in the arts.The Statewide Director of DOH-DDD has supported the festivals and partnered to sustain and expand programming. 7. Program Objectives Using County Nonprofit Grant Program Funds: With Hawai'i County Nonprofit Grant Program Funds Full Life will: 1. Expand AHA and Pua Na Pua Art Festivals to increase greater participation.Also,we will partner with Live Aloha Art Festival for inclusive puppet making, inclusive live performances(virtual or in person),dancing(virtual or in person),and a film festival. 2. Pivot to virtual formats if needed and ensure that the formats are accessible to all with virtual means to purchase art from participants. 3.Collaborate with Art Center partners to hold on-going art education classes.Current Art Center partners include: Donkey Mill Art Center in Kona,Kipaipai Art School in Puna,and East Hawaii Cultural Center in Hilo.We anticipate 30 art students with a total of 20 classes during the year. 4. Continue to increase capacity for staff and volunteer coordination necessary to support the program and events. 5. Provide outreach to youth with disabilities to be included into the festivals 6. Increase income opportunities and support participants who are successful at the festivals with self-employment supports and business coaching. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Measure satisfaction of public after art festivals and likelihood of returning in future years Target 100 completed surveys noting highly satisfied Measure attendance at festivals to see if attendance is increasing over previous years Target 500 community members attending Measure the satisfaction of community partners and their involvement with Empowering Creativity Target 5 satisfied community collaborative partners Pre and post surveys of participants to measure if they developed skills or improved after classes Target 15 class participants reporting improvement in skills after classes Measure number of participants with disabilities who were satisfied with art festivals and plan to return in the future Target 30 artists satisfied with festivals and plan to participate again Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 12015 15,500 4500 Professional Fees 3578 6000 2000 Operations 3037 3500 500 Supplies 2829 3000 500 Equipment 0 2000 0 Other: Advertising and promotion 1356 2500 1000 Other: Travel and lodging 463 2500 500 Other: 0 Other: 0 Other: 0 TOTAL 23,278 projected 35,000 9000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists 'a. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor O The Managing Director O The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. . C. i LttC. kbit d—A--0' 1/20/2021 efature of Authorize erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2O21-22 Agency Name: Full Life Program Name: Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. %4 . re '/ 1/20/2021 , •igna• re of Authorized Pers ►oll Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Full Life Program Name: Empowering Creativity- Pua Na Pua and Abled Hawai'i Artists 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Measure satisfaction of public after art festivals and likelihood of returning in future years Target log completed surveys with highly sat++ Measure attendance at festivals to see if attendance is increasing over previous years Target 500 community members intending Measure the satisfaction of community partners and their involvement with Empowering Creativity Tomei 5satisfied cemmuniymgabo veper Pre and post surveys of participants to measure if they developed skills or improved after classes Targe115 class padiclpants reporting Improver Measure number of participants with disabilities who were satisfied with art festivals and plan to return in the future Target 30 artists satisfied withfesevals and pts TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 4500 Professional Fees 2000 Operations 500 Supplies 500 Equipment 0 Other: Advertising and promotion 1000 Other: Travel and lodging 500 Other: Other: Other: TOTAL 9000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Girls Scouts of Hawaii Hawai'i Island Girl Scout Leadership Experience 91 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Girl Scouts of Hawaii Program Name:Hawaii Island Girl Scout Leadership Experience Agency Director: Shari Chang Phone No.:(808 ) 675 —5502 Contact Person: Trina Nakamura Phone No.:(808 ) 675 —5516 Mailing Address: Address: 410 Atkinson Drive, Suite 2E1 Address: Box 3 city,sT,zip Honolulu, HI 96814 Facility Address: Address: 419 Atkinson Drive, Suite 2E1 Address: City,ST,zip Honolulu, HI 96814 Email Address: gshdevelopment@gshawaii.org Fax No.: (808 ).691 —9340 Accountant/CPA: Chris Yuen • Phone No.:( 808) 735 — 8585 Firm (if applicable): Ohata Chun Yuen LLP CPAS Mailing Address: Address: 3684 Waialae Ave. City,ST,Zip Honolulu,HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑>• Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona El North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts E Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $12,925 $8,858 $11 ,250 2.Agency Mission Statement: Girl Scouting builds girls of courage,confidence,and character,who make the world a better place. 3. Program Description: Girl Scouts of Hawaii(GSH)offers activities based on the Girl Scout Leadership Experience(GSLE),a program model used nationally and informed by rigorous research carried out by the Girl Scout Research Institute.GSLE provides girls ages 5-18 with opportunities to acquire leadership abilities and develop their aptitude in STEM(Science,Technology, Engineering and Mathematics)fields. At the heart of GSH programming are adventures in STEM,the outdoors,life skills,and entrepreneurship.Girls set and achieve their goals by taking Leadership Journeys-a series of challenging learning experiences grouped around a theme. Journeys develop confidence and core values;promote healthy relationships through teamwork;encourage civic action through planning and implementation of community service projects;teach entrepreneurship through the Financial Literacy and Entrepreneurship program;and inspire challenge-seeking behavior and environmental stewardship through outdoor/camping experiences. STEM concepts are introduced in creative,age-appropriate ways through earth science,water conservation,energy awareness citizen science design thinking(engineering),and computational analysis(programming)projects.Our entire curriculum is aligned with the Hawaii Common Core State Standards. GSH's overall goal is to improve girls'leadership abilities and increase their exposure to STEM concepts and opportunities.This is accomplished by making the GSLE available to as many girls as possible.We currently serve 314 members throughout Hawaii Island, 4.Total Budget& Position Count: Total Program Budget: Total Program Position Count: 1 Total Agency Budget: Total Agency Position Count: 20 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Hawaii Island United Way 5,000 Hawaii Community Foundation East Hawaii Fund 5,000 Kukio Fund 10,000 John M.Ross Foundation 4,000 County of Hawaii Nonprofit Grant Application 40,000 Girl Scouts of Hawaii 24,149 Hawaii Community Foundation West Hawaii Fund 6,000 TOTAL: 94,149 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Girl Scouts of Hawaii relies on a diverse mix of revenue sources,with 71%coming from highly reliable and repeatable earned income,followed by 27%from public support,and 3%from government grants.We are currently seeking to increase revenue from our annual campaign and major gifts,including continuing to build a giving society that we launched several years ago whose members pledge a major gift annually for three years.Our strategic plan also calls for increasing revenue from camp rental fees,which will be made possible by attracting more users to Camp Paumalu on the island of Oahu through the building of a new STEM Center for Excellence that is projected to be completed by the end of 2021. • 7. Program Objectives Using County Nonprofit Grant Program Funds: GSH offers a variety of STEM-focused activities throughout the year in Hawaii County.The events complement the curricula and principles embedded in the Leadership Journeys.Due to COViD-19,our programming has shifted to be completely virtual,and this will continue until safety guidelines are lifted.The following is a sample of recent and upcoming STEM events: (1)At this year's virtual STEM-Fest,girls in grades K-12 sampled a wide range of STEM careers including Robotics, Environmental Science,Astronomy,Coding,and much more.They were mailed an extensive program activity kit that allowed them to participate in hands-on activities facilitated by community professionals,all virtually. (2)Due to Covid-19 restrictions,Girl Scouts of Hawaii(GSH)will continue with our recently released"Girl Scouts at Home"Program—a series of family friendly badge activities that Girl Scouts can complete at home.Videos and live webinars make it possible for GSH to deliver STEM programming,virtual campouts,and other educational opportunities for Girl Scouts and their families five times a week.ASLP troops will regularly meet virtually,and our Hawaii Island Coordinator is working with ASLP member families who lack Internet access to provide course materials via mail with staff support. (3)During the 2021-2022 membership year, Hawaii Island girls will have opportunities to attend,whether that be virtual or in person,the annual STEM Fest,a Cookie University,a Campout,and participate in World Thinking Day.Additional activities are in the planning stages. (4)Through the Girl Scouts Financial Literacy and Entrepreneurship(Cookie)Program,the largest girl-led business in the world.Girl Scouts learn and practice math skills as they aet hands-on experience in aoal-settina.decision-makina.moneva EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Girls Attending STEM Fest 90 Girls Source Hawaii Island STEM Professionals to present hands-on activities throughout the program year 20 Presenters Source volunteers for assistance Source Volunteers Maintain number of outreach program recipients 20 Girls Maintain number of Girl Scout Members 343 Girls Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 75,926 66,993 27,500 Professional Fees 175 Operations 3,573 3,356 Supplies 4,490 16,000 6,000 Equipment Other: Program Fees for ASLP Participants 2,400 1,800 1,000 Other: Postage for Activity Kits 6,000 5,500 Other: Other: Other: TOTAL 101,199 94,149 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii island Girl Scout Leadership Experience 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council U The Mayor L[( The Managing Director • The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Ca II kb I Signature of Authorized P s n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of.Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will • impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii,Island Girl Scout Leadership Experience 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/14/21 .':nature of Authorized Person Date CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Girls Attending STEM Fest 90 Girls Source Hawaii Island STEM Professionals to present hands-on activities throughout the program year 20 Presenters Source volunteers for assistance secure volunteers Maintain number of outreach program recipients 20 Girls Maintain number of Girl Scout Members 343 Girls TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 27,500 Professional Fees Operations Supplies 6,000 Equipment Other: Program Fees for ASLP Ply 1,000 Other: Postage 5,500 Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Exhibit A: Continued. 7. Program Objectives Using County Nonprofit Grant Program Funds: management, people skills, and business ethics. (5) For girls from low-income families who are in most need of services and faced with the highest barriers to participation,we offer the After School Leadership Program (ASLP).ASLP provides the same experiences as a traditional troop, but girls are not charged a membership fee.ASLP is delivered at the school at which the girls attend, in areas where it's needed most-in Title 1 schools in low-income areas. Membership fees and participation costs are often unattainable for girls from low-income areas who are likely to benefit from the program most. On Hawaii Island our ASLP troop is located at Waimea Elementary and in addition, all girls from Pahoa Elementary's fees are waived. Gong Home Hawai'i Hawaii Island Going Home Consortium 92 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Going Home Hawai'i Program Name:Hawai'i Island Going Home Consortium Agency Director: Lester Estrella, CEO Phone No.:(808 )491 —2437 Contact Person: Kimi Palacio, Program Director, East HI Phone No.:(808)491 —2437 Mailing Address: Address: 80 Pauahi St., Ste 203 Address: City,ST,zlp Hilo, HI 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: goinghomehawaii@gmail.com Fax No.: (808 ) 498 —0315 Accountant/CPA: Carbonaro CPAs and Management Group Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole St. City,sr,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $32,751.00 Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua 0 North Kona ❑■ South Hilo 0 North Kohala E South Kona 0 North Hilo 0 South Kohala 0 Kali) Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑Youth g Victims of Crimes ❑ Culture and the arts ❑Aged ❑■ Victims of Health or Social Crises ❑� Needs of the poor ❑■ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $7,925.00 $12,438.00 $6,450.00 2.Agency Mission Statement: The Hawai'i Island Going Home Consortium mission is to assist justice-involved Hawai'i Island men,women,and youth with reintegration into community life through employment,education,training,and appropriate supportive services, under the guiding light of No New Crimes,No New Victims.Consortium members consist of non-profit organizations, criminal justice agencies,mental health and substance abuse treatment providers,educational providers,employment specialists,housing specialists,and concerned community members from both East and West Hawai'i. Because our target population of justice-involved individuals,particularly those recently released from custody,has complex needs,these efforts adopted a comprehensive approach that centers on employment and training,as well as includes components critical to employment success,including education,housing,transportation,and treatment services for substance abuse and mental health. The Consortium responds to the over-representation of Native Hawaiians in the criminal justice system and the impact on the family through a wellness-focused effort that helps reunify justice-involved individuals with their`ohana and other community members as é ho'okanaka(persgns of Worth).Supportive services include an intensive,co-case management approach,mentoring,and spacial programs onlHawaiian cultural practices such as ho'o ponopono(reconciliation and forgiveness). ' Our efforts also contribute to increasing public safety and reducing costs to our public systems by alleviating overcrowding at Hawai'i Community Correctional Center and reducing the continuous cycling in and out of jail of Native and non-Native Hawaiians who are mentally ill and chronically homeless. 3. Program Description: Community efforts to address the successful reentry and recovery of individuals released from custody on Hawai'i Island began in 1999 with the creation of the Hawai'i Island Corrections Advisory Commission(HICAC). In 1997,the State decided to build a large prison on the Big Island to alleviate severe overcrowding in its correctional facilities.To ensure community input,the Department of Public Safety convened a community advisory committee(later to be called HICAC),which consisted of representatives of a wide cross-section of the community. Since 2004,the group,now known as the Hawai'i Island Going Home Consortium, has continued to meet monthly with an average attendance of 20-30 individuals.Members include other non-profit organizations,criminal justice agencies, mental health and substance abuse treatment providers,educational providers,employment specialists, housing specialists,and concerned community members from both East and West Hawaii. In May of 2015,Going Home Hawai'i (GHH)was established as the nonprofit branch and the governing fiscal body of the Consortium.The Hawai'i Island Going Home Consortium is a fluid and grassroots entity serving all of Hawai'i County in which all members volunteer their time to participate in monthly meetings,awareness events,and individual committee activities geared towards promoting successful outcomes for our target population. Committees include Career Pathways, Cultural Competency, Faith-based, Health and Housing,Justice Partners,and the West Hawai'i Coalition. Reflecting local culture,the Consortium's activities have been rooted in meeting face to face and often sharing meals together.While we have been able to transition to Zoom online meetings or phone calls in the emergency short-term,a critical component of the upcoming fiscal year is developing a 5-year Strategic Plan that will identify avenues by which we can effectively and sustainably engage diverse media platforms to collaborate and deliver services without weakening partnerships or impact.At the same time,offering services online has also enabled us to expand our program reach and better connect East and West Hawai'i. 4.Total Budget& Position Count: Total Program Budget: $32,751.00 Total Program Position Count: 3 Total Agency Budget: $571,800.00 Total Agency Position Count: 12 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Nonprofit Grant Application $32,751.00 Annual Fundraising Event(anticipated) $5,200.00 Donations(in-kind) $5,395.00 Blueprint For Change(pending) $1,804.00 Hawaii State Dept.of Public Safety(pending) $1,804.00 TOTAL: $46,954.00 Attach additional pages,if needed. ' 6. Explain what plans your agency or program has to increase revenues to support this program: Our annual benefit dinner and silent auction,"Hol'Hou I Ka Mole"(Return to the Root),had to be cancelled in 2020 due to COVID-19.As part of our pivot,we are planning to hold it online,but without the silent auction.As our focus on directly addressing the issue of overrepresentation of Native Hawaiians in the criminal justice and correctional systems has deepened,we hope to obtain support from the Office of Hawaiian Affairs(OHA)and the Administration for Native Americans(ANA)on future projects. We anticipate raising funds through other supporters,especially as the pivot to strengthening our partnerships and community online.Future revisibns to GHH's website include a giving page with an online donor portal. The Consortium is also actively pursuing collaborative efforts with other local nonprofits to maximize our resources. 7. Program Objectives Using County Nonprofit Grant Program Funds: See Attachment A. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawaii Program Name: Hawaii Island Going Home Consortium 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) See Attachment B. Attach additional pages as necessary. 9.TABLE II: I i PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees - $361.00 $28,000.00 $24,000.00 Operations $5,904.00 $1,804.00 Supplies $219.00 Equipment Other: Educational training &workshop materials $1,006.00 $7,215.00 $1,820.00 Other: Events (Awareness & Employer Recognition) $1,103.00 $150.00 $150.00 Other: Mini grants $1,077.00 $2,000.000 $2,000.00 Other: Emergency supplies for program participants $2,683.00 Other: Administration expenses $2,977.00 $2,977.00 TOTAL $6,450.00 $46,246.00 $32,751.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict.of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor Di The Managing Director The Director of Finance 0 Th'e Corporation Counsel;the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: nj If no conflicts exist, check here. 4/2//, e d cl v y 9-9 .2_02_1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawaii Program Name: Hawaii Island Going Home Consortium 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and;ability to fully administer the program(s) pursuant to law. I (we) understand that informationsupplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawai'i Program Name: Hawaii Island Going Home Consortium ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in,the application;except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for'Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. afrkrA- Le.4 (3A-7,A/4-aya-, 202/ Signature of Authorized Person Date c9-01 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result See Attachment C. TABLE II: FY 21-22 Council PROGRAM;EXPENDITURES Grant Request Award Salary and Wages Professional Fees $24,000.00 Operations $1,804.00 Supplies Equipment Other: Educ. training & materials $1,820.00 Other: Events: Awareness, etc. $150.00 Other: Mini grants $2,000.00 Other: Administration expenses $2,977.00 Other: TOTAL $32,751.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Going Home Han Program Name: Hewer' Island Going Home Consortium ATTACHMENT - A 7. Program Objectives Using County Nonprofit Grant Program Funds 1) Coordinate, facilitate, and implement follow up of regular Consortium meetings, online and/or in-person in compliance with government guidelines, including organizing the general activities and agenda for the meetings and keeping members informed of meeting activities and outcomes. 2) Develop and implement a 5-year strategic plan, including a business pivot from a traditional reliance on in-person meetings/interactions to using diverse media for delivery of services and partner collaboration effectively and sustainably. 3) Develop and implement a community multi-media room to engage with and create digital content, to be used by Consortium and community members, as part of the business pivot. 4) Assist with the coordination and facilitation of individual committee meetings and activities in focus areas such as Cultural Competence, Health & Housing, and Restorative Justice. 5) Coordinate and facilitate verbal intervention strategy training for Consortium members. This will include training of two (2) GHH staffers, who will then lead training sessions to members. 6) Coordinate awareness events and activities to promote the need for recovery and reintegration services, including GHH's web and social media resources. 7) Coordinate and facilitate an online Employer Recognition event to honor East Hawai'i employers who hire those released from custody. 8) Provide mini-grants of up to $250 each (total of$2,000) for Committee events and activities, such as gift cards/incentives for speakers for Victim Impact Classes. 9) Provide Cultural Practitioners for four(4) 10-session cultural programs for the participants of the East Hawaii Pu'uhonua Wellness Centers. Two programs for women and two for men, with one (1) experienced Cultural Practitioner per program. 1 Comm- of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Going Home Hewer' Hawaii Island GoinHome Consortium Program Name: 9 ATTACHMENT - B 8. Table I What are the measurable performance outcomes that would be achieved with this funding? Program Performance Measures Applicant Projected Results Monthly Consortium meetings (online) 12 meetings Five-year strategic plan, including a business pivot to media platforms 1 plan Community multi-media room 1 room Meetings and activities of Consortium individual committees 6 committees Verbal intervention strategies training for Consortium members (online) 4 trainings Recovery and reintegration awareness events (online) 4 events Employer Recognition Event (online) 1 event Mini-grants to support Consortium committee activities $2,000 in total mini-grants Four (4) 10-session cultural program for residents of recovery reintegration 4 programs housing in East Hawaii, led by Cultural Practitioners (online) 2 County of Hawaii Nonprofit Grant Application FY2O21-22 Agency Name: Going Home H�ir�ll'i Program Name: Hawaii Island Going Home Consortium ATTACHMENT - C 12. COUNCIL AWARD WORKSHEET Table I: Program Performance Measures Applicant l Council Proposed Projected Results ! Projected Result Monthly Consortium meetings (online) 12 meetings Five-year strategic plan, including a business pivot to 1 plan media platforms Community multi-media room 1 room Meetings and activities of Consortium individual 6 committees committees Verbal intervention strategies training for Consortium 4 trainings members (online) Recovery and reintegration awareness events (online) 4 events Employer Recognition Event (online) 1 event Mini-grants to support Consortium committee activities $2,000 in total mini-grants Four (4) 10-session cultural program for residents of 4 programs recovery reintegration housing in East Hawai'i, led by Cultural Practitioners (online) 3 Goodwill Industries of Hawai`9D Inc. Career Services 93 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services Agency Director: Katy Chen Phone No.: (808)836 — 0313 Contact Person: Emily Lau Phone No.: (808)792 — 5072 Mailing Address: Address: 2610 Kilihau Street Address: City,ST,zip Honolulu, HI 96819 Facility Address: Address: 200 Kanoelehua Avenue Address: Suite 102 city,sr,zip Hilo, HI 96720 Email Address: Elau@higoodwill.org Fax No.: (808)833 — 4943 Accountant/CPA: Phone No.: (808)524 —2255 Firm (if applicable): N & K CPA's, Inc Mailing Address: Address: 999 Bishop Street Suite 2200 city,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna Hamakua ❑1 North Kona ❑■ South Hilo ❑North Kohala Q South Kona Q North Hilo ❑South Kohala ❑ Keil Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 8800 5500 10250 2.Agency Mission Statement: Goodwill Hawaii mission is to"help people with employment barriers reach their full potential and become self sufficient". Goodwill Hawaii is accredited by the Commission on Accreditation of Rehabilitation Facilities(CARF). For over 60 years, Goodwill Hawaii has successfully reached and provided services to over 10,000 people annually;providing support with educational opportunities,access to vocational and trainings,social services, and workforce development. 3. Program Description: Goodwill's Career Services has been providing employment services to low income persons and reintegrating individuals within Hawaii county with the goal of assisting participants find and maintain gainful employment. The program provides individualized services beginning with a comprehensive assessment to determine ones strengths,abilities and barriers that affects employability.This service leads into the development of an individualized program plan where participants are assisted in identifying their desired employment goal and objective. This plan acts as their road map to success and self-sufficiency. With an agreed plan,participants are provided Job Readiness training. These evidence based trainings cover a variety of valuable topics including cover letter and resume writing, interviewing,and job search skills and strategies. Once a participant becomes employed,they are provided post employment services where participants are followed up for up to six months to ensure they are acclimating well to their work environment and to address any work related issues/concerns.Career Services also supplements services with other program services including career counseling/job coaching,vocational training referrals and tuition assistance,case management,and collaboration with many community partners and providers such as Alu Like,The American Job Center,various vocational training schools, and other human services organizations.Through these partnerships and internal and external referrals,participants are provided holistic services to help them overcome barriers,meet their goals and attain self-sufficiency. Goodwill's Career Services will use the support from Hawaii County Non-profit Grant to increase staffing so we can enhance business engagement efforts.With the impact from the COVID-19 pandemic,Hawaii island businesses had to face tremendous challenges.Many had to reduce operations or shut down.As a result, many workers lost their job.We plan to increase connections with businesses,identify their needs, provide assistance to workers who lost their job,and develop job opportunities for Career Services program participants. 4.Total Budget& Position Count: Total Program Budget: $600,000 Total Program Position Count: 7 Total Agency Budget: $3,000,000 Total Agency Position Count: 80 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii-Office of Community Services $170,000 WIOA Adult and Dislocated Worker Services $400,000 County of Hawaii Non-profit Grant $30,000 TOTAL: $600,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Goodwill Hawaii continuously seeks out additional resources/funding to support Career Services through other federal, state and private grant opportunities.Goodwill will also continue to leverage existing resources including facilities and administrative services to increase revenue to support an employment counselor for Career Services in Hawaii County. 7. Program Objectives Using County Nonprofit Grant Program Funds: Goodwill's Career Services provides needed support to our low income residents in Hawaii County offering opportunities to become financially stable and self sufficient. The objectives for Career Services with the support through an Employment Counselor are to increase: 1.Enrollment into the Career Services Program 2.Virtual Job Readiness Training options 3.Business/Employer engagement activities and coordinate industry specific on-site interviews for participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Intake!Assessment 100 Job Readiness Training(in person and Virtual) 55 Job Placement 40 30-Day Retention 35 Business/Employer Engagement activities 24 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 280,000 415,000 $30,000 Professional Fees 10,000 20,000 Operations 50,000 80,000 Supplies 7,000 20,000 Equipment 2,000 5,000 Other: Client Assistance Expenses 20,000 60,000 Other: Other: Other: Other: TOTAL 369,000 600,000 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council ® The Mayor El The Managing Director ® The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. 27(4,• -, C�/G��i�- 2 - Carl.�e�-I Signature of thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai`i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountygov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report-is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. aZ d2 y , _2 / Signature of AUtthorized Person Date President/CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Intake/Assessment 100 Job Readiness Training (in person and Virtual) 55 Job Placement 40 30-Day Retention 35 Business/Employer Engagement activities 24 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 30,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Goodwill Industries of Hawai`'i, Inc. Ho'olana Educational and Arts Program 94 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program Agency Director: Katy Chen, President/CEO Phone No.: (808)836 — 0313 Contact Person: Kevin Bardsley-Marcial,Director of Intelluctual Disability Phone No.: (808)836 — 0313 Mailing Address: Address: 2610 Kilihau St Address: City,ST,zip Honolulu, HI 96819 Facility Address: Address: 500 Kalanianaole Ave Address: Suite 3 city,s-r,zip Hilo, HI 96720 Email Address: kbardsley-marcial@higoodwill.org Fax No.: (808)836 — 2579 Accountant/CPA: Phone No.: (808)524 —2255 Firm (if applicable): N & K CPA's Inc Mailing Address: Address: 999 Bishop St Suite 2200 city,sr,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua ❑ North Kona ❑■ South Hilo ❑North Kohala ❑South Kona ID North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes Q Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑t Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,300 $6,200 $11 ,500 2.Agency Mission Statement: Goodwill Hawaii's mission is to,"Help people with employment barriers reach their full potential and become self-sufficient."A nationally accredited Mission Services provider,Goodwill Hawaii has served the state of Hawaii as a reputable non-profit organization for 60 years,providing education,workforce development,and social services to more than 10,000 people annually. 3. Program Description: The Ho'olana Program provides person-centered training services to people with developmental/intellectual disabilities to help them develop skills and increase independence.The Educational and Arts Program will provide the opportunity for individuals with an intellectual/developmental disability to become entrepreneurs by exploring the Hawaiian culture and their own ancestral heritage.They will be able to connect with members of the community and local artists to showcase their own talents and abilities in the world of art. The participants will be provided an educational insight to the different cultures and experiences that the island of Hawaii has to offer.They will use tools such as an embroidery machine,computer program and software to create original art pieces.This year we plan to incorporate a new ancestry club that uses genetic testing to establish individual's heritage. Participants would be able to participate in doing ancestry research through DNA testing like Ancestry or 23 and Me.They will also be using digital art to create bags,t-shirts,coasters etc.that could be sold at various community events. During the course of the program,the participants will learn about the culture of the community that they live in and their own heritage to help create beautiful works of art that can be sold to community members.The participants will also learn the importance of creating a business based on the needs of the community,how to sustain a business,and how to sell and earn a sustainable income independently. The fund from Hawaii County Non-profit grant will be used to purchase equipment and supplies for the Education and Arts program,especially in creating and setting up the new ancestry club.The fund will also support staffing and contracted instructors to provide training and teaching on producing various arts. 4.Total Budget& Position Count: Total Program Budget: $340,000 Total Program Position Count: 7 Total Agency Budget: $3,000,000 Total Agency Position Count: 80 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii $300,000 County of Hawaii Non-profit Grant $40,000 TOTAL: 340,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will be used to enhance the scope of services currently offered to the program participants.The Ho'olana Educational and Arts Program will focus on the participants heritage and history and add value to their quality of life and the people around them.The participants will be able to develop new skill sets and have access to additional resources.Overall,the value of the program will increase interest to the broader community due to the various community events that the participants will be able to access,therefore promoting the program to the greater community.Exposure of the program will increase enrollment for people with an intellectual /developmental disability,therefore increasing program revenue. The increase in revenue will help sustain the program financially,long-term.The Ho'olana Educational and Arts Program is part of Goodwill Hawaii's Ho'olana program and aligns with Goodwill's overall mission of overcoming barriers to employment,specifically for individual's with an intellectual/developmental disability.The Ho'olana Program encourages and motivates the participants to become contributing members of the society by learning to be as independent as possible.Goodwill's Ho'olana program who serves adults with an ID/DD is known in the community as a program that gives back to the community while advocating for the vulnerable populations in the program.Goodwill maintains a positive reputation in the community,and acknowledges how important the community is to Goodwill. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives for the Ho'olana Educational and Arts Program will be to: 1.Provide individualized educational opportunities that focuses on community,history,and the culture of Hawaii and their own ancestors 2.Provide the necessary tools to help the participants gain and retain new entrepreneurial skills 3.Provide an income to the participants participating in the Program 4.Provide daily living skills to enable the participants to become self-sufficient The Ho'olana Educational and Arts Program plays a vital role in helping our participants with an Intellectual/ Developmental disability become a part of their community free of apprehension of the unknown.They will also develop basic business skills while creating a future career possibility to live an independent,healthy and happy life. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Ho'olana Educational and Arts Program-number of participants 25 Number of participants who gained new skills 20 Number of participants who obtained additional income 5 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 200,000 250,000 $18,000 Professional Fees 2,000 5,000 Operations 80,000 50,000 $3,000 Supplies 5,000 10,000 $10,000 Equipment 1,000 15,000 $5,000 Other: Training/Consultant 5,000 $4,000 Other: Specific Assistance to Participants 3,000 5,000 Other: Other: Other: TOTAL 291,000 340,000 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor The Managing Director ® The Director of Finance ® The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■ If no conflicts exist, check here. e/A(2-- --- Signature of A horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Career Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person Date President / CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ho'olana Educational and Arts Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Ho'olana Educational and Arts Program -number of participants 25 Number of participants who gained new skills 20 Number of participants who obtained additional income 5 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 18,000 Professional Fees Operations 3,000 Supplies 10,000 Equipment 5,000 Other: Training/Consultant 4,000 Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Goodwill Industries of Hawai`u, Inc. Ula I Ka Nana Youth Program 95 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Hana Youth Program Agency Director: Katy Chen, President/CEO Phone No.: (808)836 — 0313 Contact Person: Emily Lau,Vice President of Mission Services Phone No.: (808)792 — 5072 Mailing Address: Address: 2610 Kilihau Street Address: City,sr,zip Honolulu, HI 96819 Facility Address: Address: 500 Kalanianaole Avenue Address: Suite 3 City,ST,Zip Hilo, HI 96720 Email Address: Elau@higoodwill.org Fax No.: (808)833 — 4943 Accountant/CPA: Phone No.: (808)524 —2255 Firm (if applicable): N & K CPAs, Inc. Mailing Address: Address: 999 Bishop Street Suite 2200 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑ Hamakua M North Kona ❑■ South Hilo ❑ North Kohala ❑u South Kona 0 North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth ❑Victims of Crimes 0 Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Hana Youth Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,500.00 2.Agency Mission Statement: Goodwill Hawaii's mission is to"help people with employment barriers reach their full potential and become self-sufficient." Goodwill's teams have provided dependable and effective services to disadvantaged youth participants in the Ola I Ka Hana Youth Program.Goodwill's Youth Specialists possess knowledge of the local communities,and our confirmed experience delivering services to youth with diverse background in Hawaii County helps Goodwill to achieve positive performance results. 3. Program Description: Goodwill Hawaii proposes to provide services to at-risk youth ages 14-24,facing significant barriers to employment and academic achievement through our established Ola I Ka Hana Program. Goodwill has continued to provide support and services to youth residing on Hawaii Island through grants received by the Workforce Innovations and Opportunities Act (WIOA)and the current County of Hawaii Nonprofit Grant. Goodwill strongly believes in empowering the people we serve by creating innovative programs to develop positive behaviors for a healthy,safe life,and achievement of success from youth throughout adulthood. Youth will continue to be provided with educational support by program staff and supplies needed for them to progress in their personal growth. The support provided by the Hawaii County Grant will allow Goodwill to purchase additional educational software and supplies such as:Odysseyware(provides instructional support to students. Students have a variety of embedded support tools and scaffolds at their fingertips in every lesson,including literacy,fluency,and audio scaffolds. They also receive immediate feedback throughout lessons and assessments to guide their learning),and additional student/teacher work books(math,reading,Career Pathways and Job Readiness Training).There are increased demand to utilize web-based educational software due to the need to deliver services virtually because of COVID-19 restrictions.The Hawaii County Nonprofit Grant will also increase staffing to support more youth.We expect the number of youth needing services to increase since many youth did not get enough help and assistance through their school because of restrictions in on-campus education. 4.Total Budget&Position Count: Total Program Budget: $380,000 Total Program Position Count: 5 Total Agency Budget: $3,000,000 Total Agency Position Count: 80 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Hana Youth Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate WIOA Out-of-School and In-School Youth Contract $350,000 County of Hawaii Non-profit Grant $30,000 TOTAL: $380,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will help support the increased demand for Ola I Ka Hana Youth Program services.Goodwill Hawaii will seek additional private and public grant opportunities to help support and expand Ola I Ka Hana Program.Goodwill will also continue to use existing resources including facilities and administrative services,as well as other current public and private funds to support current services. 7. Program Objectives Using County Nonprofit Grant Program Funds: The requested funds will continue to help the Ola I Ka Hana Program to amplify educational and employment services that are in place.The objective is to assist youth to increase their proficiency levels in math and reading as well as afford them the opportunity to identify a career pathway of their interest. With the new educational tools,youth will have the ability to meet or approach proficiency levels and be able to identify a career pathway of choice. Being able to identify what career pathway they want to go into is important as we want youth to leave the program confident and to be responsible contributing young adults. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Hana Youth Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of participants completed intake 30 Number of assessments completed 30 Number of participants enrolled in Basic Skills Math 20 Number of participants enrolled in Basic Skills Reading 20 Number of participants enrolled in HiSET(Diploma Track) 20 Number of participant identified a Career Pathway 30 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 190,000 267,000 $18,000 Professional Fees 3,000 4,000 Operations 50,000 70,000 $2,000 Supplies 5,000 7,000 $10,000 Equipment 1,000 2,000 Other: Client support services, tuition, training 15,000 30,000 Other: Other: Other: Other: TOTAL 264,000 $380,000 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Nana Youth Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ® Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance ® The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■j, If no conflicts exist, check here. 7i1,1Com. "'t ,2 .9-- 9 tea-/ Signature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka liana Youth Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Nana Youth Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Au orized Person Date President / CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Ola I Ka Hana Youth Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants completed intake 30 Number of assessments completed 30 Number of participants enrolled in Basic Skills Math 20 Number of participants enrolled in Basic Skills Reading 20 Number of participants enrolled in HiSET (Diploma Track) 20 Number of participant identified a Career Pathway 30 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 18,000 Professional Fees Operations 2,000 Supplies 10,000 Equipment Other: Other: Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Grassroots Community Development Group Hawai'i Youth Business Center: Media Literacy 96 ii County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy Agency Director: Trina Nahm-Mijo Phone No.:(808 )640 —5109 Contact Person: Trina Nahm-Mijo Phone No.:(808 )640 —5109 Mailing Address: Address: PO Box 1772 Address: City,ST,Zip Keeau, HI 96749 Facility Address: Address: 17-4205 13 Mile Rd. Address: City,ST,Zip Kurtistown, HI 96760 Email Address: nahmmijo@hawaii.edu Fax No.: (808 )974 —7757 Accountant/CPA: John Carbonaro Phone No.:(808 ) 968 —1002 Firm (if applicable): Carbonaro CPA & Assocs. Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑s Puna ❑ Hamakua ❑ North Kona g South Hilo ❑ North Kohala ❑South Kona ❑■ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged Q Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities Rol Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $4,800 $8,069 $18,750 2. Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for east Hawai'i.To provide quality programs for youth and families. 3. Program Description: The Hawaii Senate passed SB 2070 in 2018 recognizing the importance of Media Literacy as a"necessary skill that allows all citizens to access, analyze, and evaluate information using a variety of forms of communication. . .and that "instruction in media literacy should be incorporated into every classroom and every curriculum content area to prepare students to live and work in a digital world." In FY 2019-2020, our Media Literacy program_reached over 200 students. When COVID hit in the beginning of 2020,our organization met the challenge by modifyni our.:Media Literacy program to be delivered over Zoom and continued to develop lessons that can be delivered in an online format. We now have developed a healthy 20 lesson curriculum which can be delivered as a stand alone curriculum in school or after school, as well as modified to fit into classes like citizenry and communications with our specialist working in collaboration with classroom teachers. Because of the huge impact social media plays in every aspect of public life, especially during a pandemic, it is critical that our youth become aware of the pitfalls as well as the advantages of this instrument of communication.We have also found that because parents have to monitor their children's education over the computer in these COVID times, it is a good opportunity to educate parents as well as a family activity.The curriculum features topics like: 1)What is Media Literacy?;2)Persuasion, Manipulation&Deception; 3)The Power of Images; 4)Fake News; 5)Social Media: Risks and Benefits; 6)Social Media and Your Emotions;7)Online Safety 8) Cyber-Bullying:9)Tricks Used in Commercials; and 10)Cultural and Gender Bias; 4.Total Budget& Position Count: Total Program Budget: $8,000 Total Program Position Count: 1 Total Agency Budget: $40,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Grant $7,000 Other Grant/Business Support $1,000 TOTAL: $8,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are planning to look for other grants like the Atherton and Hawai'i Community Foundation as well as partner with parent and school organizations who might be able to partially support this program as important value added to the curriculum. 7. Program Objectives Using County Nonprofit Grant Program Funds: This program is in line with the agency's objectives of: 1) Educating and strengthening families to increase the social capital of the_area. Furthermore, the program will 2)Foster the highly needed skill of Media Literacy in contemporary society amongst school-aged children and their parents;and 3) Contribute to a media literate citizenry who can distinguish between legitimate information and"fake news". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy WIEITIMMIESSIMEIRSMESi MOW 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) • 100 Youth will receive online Media Literacy education At least 30 parents will receive Media Literacy information with their children At least 4 different schools will participate in delivering the Media Literacy curriculum Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees 3500 4000 4000 Operations 400 Supplies 200 200 Equipment 1500 3000 3000 Other: Zoom Subscription 180 200 200 Other: Mileage 200 200 Other: Other: Other: TOTAL 5380 8000 7400 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy loo ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Trina Nahm-Mijo POSITION: President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 1; Member or members of the Council fl Staff appointed by a member of the Council 11 The Mayor The Managing Director The Director of Finance El The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: RI If no conflicts exist, check here. C ' I. � ��► • � 1 � I )--o Signature of Aut prized Person (. pecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 11. Certification of Understanding (Page 1 of 2) I (we) have read 'a'nd understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy is. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 4,.pt.-• 1 /28/21 Signature of Authori ed P-rson Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 7 of 8 County of Hawai i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center: Media Literacy 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Grassroots Community Development Group Hawai'i Youth Business Center: OIa'a Skatepark Phase II 97 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group e Program Name: Hawai'i Youth Business Center: Ola'a Skat park, Phase II Agency Director: Trina Nahm-Mijo Phone No.:(808 )640 —5109 Contact Person: Trina Nahm-Mijo Phone No.:(808 )640 —5109 Mailing Address: Address: PO Box 1772 Address: City,ST,zip Keeau, HI 96749 Facility Address: Address: 17-4205 13 Mile Rd. Address: City,ST,zip Kurtistown, HI 96760 Email Address: nahmmijo@hawaii.edu Fax No.: (808 )974 —7757 Accountant/CPA: John Carbonaro Phone No.:(808 ) 968 —1002 Firm (if applicable): Carbonaro CPA & Assocs. Mailing Address: Address: PO Box 4372 City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona ❑o South Hilo ❑ North Kohala ❑South Kona El North Hilo South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth E Victims of Crimes ❑ Culture and the arts ❑Aged 0 Victims of Health or Social Crises 0 Needs of the poor D Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $4,800 $8,069 $18,750 2. Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for east Hawaii. To provide quality programs for youth and families. I 3. Program Description: In 2019-2020, GCDG received permssion and funding to take the old, abandoned tennis courts in Kurtistown Park and transformed it in to a streetstyle skate plaza,the only one if its kind on the Big Island.Since it's opening in June 2020, it has been used daily by youth and their families as a much needed healthy recreational facility and a place for more experienced skaters to mentor ones just getting into the sport. The next phase of the skatepark development involves a handicapped ramp to make it comply with State law to be handicapped compliant. Besides the ramp buildout, GCDG would like to improve and beautify the hill in back of the skating facility with native plants to prevent flooding and to make an area where older family members can rest and wait for their children.The second phase will also involve smoothing out the surface with concrete and creating one more skating sculpture for the skaters. 4. Total Budget & Position Count: Total Program Budget: $20,000 Total Program Position Count: 0 Total Agency Budget: $40,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Grant $15,000 Fundraising Event $ 5,000 TOTAL: $20,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will organize an annual fundraising event which will be held at the Ola'a Skatepark site,and seek support from area businesses. • 7. Program Objectives Using County Nonprofit Grant Program Funds: As stated in GCDG's By-Laws,two of the organization's objectives will be addressed by this continuing project: 1)Community capacity building, including community leadership of its members of al ages, and 2) Educating and strenghthening families families to increse the social capital of the area.The skatepark has already created a safe and healthy physical outlet for youth and their families as well as social bonding which lessens the risk factors for youth to get involved in negative social behaviors like drugs and delinquency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) The Skatepark is averaging 15 different users per day/x 7 days x 52 wks.=3,640 uses/yr. With the Phase 2 beautification and skatepark additions it is estimated to rise to 5000 uses/yr. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees $5,000 $5,000 $5,000 Operations Supplies • Equipment $5,000 Other: Construction materials $5,000 $10.000 $10,000 Other: Planting materials $2,000 Other: Machinery operations $5,000 $ 5,000 Other: Maintainence $2,000 Other: TOTAL $15,000 $24,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Trina Nahm-Mijo POSITION: President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ll Member or members of the Council O Staff appointed by a member of the Council ® The Mayor Eli The Managing Director la The Director of Finance Di The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: DI If no conflicts exist, check here. yz_s1.2_1 Signature of Authoriz d P- son (specify itle! ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2 - 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to , complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. .o 1 /28/21 i 4,/.rat i a I na4rn_ Signature ofAuthoriz;d Berson ) Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a Skatepark, Phase II 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Grassroots Cornmunity Development Group La'au 'Ohana Ekolu 98 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu Agency Director: Trina Nahm-Mijo Phone No.:(808 )640 —5109 Contact Person: Trina Nahm-Mijo Phone No.:(808 )640 —5109 Mailing Address: Address: PO Box 1772 Address: city,ST,Zip Keeau, HI 96749 Facility Address: Address: 17-4205 13 Mile Rd. Address: city,ST,Zip Kurtistown, HI 96760 Email Address: nahmmijo©hawaii.edu Fax No.: (808 )974 —7757 Accountant/CPA: John Carbonaro Phone No.:(808 ) 968 —1002 Firm (if applicable): Carbonaro CPA & Assocs. Mailing Address: Address: PO Box 4372 City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua 0 North Kona 0 South Hilo ❑ North Kohala 0 South Kona 0 North Hilo ❑South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns 0 Youth Q Victims of Crimes ❑ Culture and the arts ❑® Aged ❑® Victims of Health or Social Crises —11 Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $4,800 $8,069 $18,750 2. Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for east Hawai'i.To provide quality programs for youth and families. 3. Program Description: The importance of integrating Hawaiian cultural practices into our community treatment, mental health and health and wellness approaches has been documented in the last decade. However, these practices are still at the cutting edge of services provided to our families. La'au 'Ohana Ekolu is an effort to spread the knowledge to both service givers and families about how to bring wellness and harmony to daily situations of crisis and conflict, thus preventing long-term chronic physical and mental illness.This program is a continuation of the work started by GCDG last FY which trained 30 community participants, many professionals in human service agencies within the community.This training was an offshoot of a training sponsored by the Non-Profit Aha Kane program implemented in 2018-2020 which trained working social service professionals in the methods of Ho'oku'u Ka Hewa(individuals and groups)and Ho'oponopono(family)to resolve conflict and harmonize relationships to two cohorts in Hilo(19 participants)and Kona (7 participants). Our program will continue under the leadership of one of the four certified Hakus, Lahela Kruse, who was the Kumu for the Hilo/Kona cohort program piloted by Aha Kane. Lahela Kruse was the sole mentee of esteemed Kumu Ulu Garmon (Kanaka'ole)and was uniki'ed by Kumu Lynette Paglinawan. in 2018. The 2nd year training will consist of one two hour intensive each month from August 2021-June 2022 with continued practice of hands-on homework for the participants to engage in between sessions.The training will further support the addition of a 1 hr.of Hula and'Olelo 2x/month taught by Kumu Kaua Kanaka'ole loane(Halau 0 Kekuhi)to deepen the learning of Hawaiian culture and practices as associated with the Ho'oku'ukahewa and Ho'oponopono practices. 4. Total Budget & Position Count: Total Program Budget: $10,000 Total Program Position Count: 2 Total Agency Budget: $40,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu Nal 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Grant $9000 Other grants $1000 TOTAL: 10,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: GCDG will be looking for other grants and funding from community partners and agencies like Aha Kane. 7. Program Objectives Using County Nonprofit Grant Program Funds: Community capacity building will be achieved by: 1)Increasing the number of professionals and individuals who have working knowledge of the Hawaiian cultural practices of Ho'oku'u Ka Hewa and Ho'oponopono in our Puna community 2) Increasing the use of Hawaiian cultural practices in our social service agencies, health centers and families. 3) Decreasing the amount of physical and mental illness problems in our families and communities by empowering them with culturally sound practices and effective tools for decision-making. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 30 Participants will enter 2nd year training with the added elements of Hula and'Olelo integrated with Ho'oku'ukahewa and Ho'oponopono 20 new participants will begin the Ho'oku'ukahewa/Ho'oponopono training 25 Hilo/Kona past trainees will have quarterly follow-ups to maintain their practice 200+family members will be positively affected by the participants increased knowledge in Hawaiian practices 550+community members will be positively impacted by service givers'integration of new knowledge and skills into their interactions with clients. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees $6000 $8000 $8000 Operations 250 Supplies 500 500 Equipment Other: Other ingredients and Kihei 1000 1000 Other: Other: Other: Other: TOTAL $6750 $10,000 $9000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Trina Nahm-Mijo POSITION: President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): El Member or members of the Council in Staff appointed by a member of the Council The Mayor fl The Managing Director The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. JAz /,CSI: • , r Signature of Authorized •erson (spe'ify title) Date I- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ghana Ekolu 05022:13129=02211221142? amizzemszmunnerma 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to • , complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai`i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. > i / t.._. 1 /28/21 Signature of Authoriz d Pe `on Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Grassroots Community Development Group Program Name: La'au 'Ohana Ekolu 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Habitat for Humanity Hawai'i island Nanawale Builds: Kilauea Recovery 101 County of Hawai6 i Nonprofit Grant Application FY2021-22 Agency Name: Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery I Agency Director: Patrick Hurney Phone No.: (8(,1336— 8010 Contact Person: Shauna Falgout Phone No.: (8C4 336— 8010 Mailing Address: Address: PO Box 4619 4 Address: City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: 73-4161 Ulu Wini Place Address: Bay 1 City,ST,Zip Kailua-Kona, HI 96740 Email Address: shauna.falgout@habitathawaiiisland.org Fax No.: ( ) — Accountant/CPA: Alex J. Smith Phone No.: (8474— 7761 Firm (if applicable): Alex J. Smith, CPA Mailing Address: Address: 1403 Frank Street City,ST,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) W Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala• ❑ Kalif Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged Q Victims of Health or Social Crises 0 Needs of the poor 111Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Iawai`i Nonprofit Grant Application FY2021-22 Agency Name: Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $19,300 $23,750 $0 2.Agency Mission Statement: Habitat for Humanity Hawaii Island(HFHHI)brings people together to build homes,communities,and hope. HFHHI is dedicated to eliminating substandard housing locally and worldwide through constructing,rehabilitating and preserving homes;by advocating for fair and just housing policies;and by providing training and access to resources to help families improve their shelter conditions. Habitat for Humanity was founded on the conviction that every man,woman and child should have a simple, durable place to live in dignity and safety,and that decent shelter in decent communities should be a matter of conscience and action for all.HFHHI shares a vision with Habitat for Humanity International:a world where everyone has a decent,safe, and affordable place to live. Affordable housing is a critical human need.Secure and affordable shelter has been linked to a number of positive community outcomes for individuals at all stages of life.Children in secure housing experience better educational outcomes,including higher graduation rates.Affordable,decent shelter can lead to less incidence of domestic violence, substance abuse,and recidivism.Habitat partner families have reported other positive social outcomes as well including improved familial relations,greater mental and physical health,and more positive community engagement. 3. Program Description: HFHHI's housing program provides affordable home ownership opportunities for families earning between 30-80%AMI in Hawaii County. Partner families are qualified based upon three criteria: 1.)Need-HFHHI uses the HUD income limits based upon Hawaii County's median income of$70,100. Families must earn between 30-80%AMI to qualify and currently be living in substandard housing.2.)Ability to Pay-Families must earn an adequate income to pay an affordable mortgage,generally around$400-600 monthly,including property taxes and community maintenance fees.3.)Willingness to Partner-Partner families are required to commit 150 volunteer hours per head of household and a total of 500 hours per family.Our organization's current focus is developing affordable housing in the Puna District,an area with a high level of poverty(30%,U.S.Census)and housing stock diminished by the 2018 Kilauea volcano eruption. Currently,there is a very high demand for affordable housing in Hawai'i County.The County assigned housing as a high priority in the most recent Consolidated Plan(2020-2024),outlining a need for an additional 13,300 new housing units to be developed just to meet the current demand.No one organization or entity will be able to solve the housing crisis alone.A multi-sector and inter-organizational effort is required to make a positive impact in our local communities. Many of the low-income families on our inquiry list are single-parent households with children,women,elderly or are living with a disability.Hawaii is home to one of the highest shelter-to-income ratios in the nation; meaning that many people in these categories will be cost-burdened by their rent or mortgage,meaning that over 30%of the household income goes directly to shelter costs.Habitat mortgages are designed so that no family will ever have to pay over 30%of income to housing. 4.Total Budget.& Position Count: Total Program Budget: 667,500 Total Program Position Count: 3 Total Agency Budget: 2,486,016 Total Agency Position Count: 19 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Nonprofit Grant $50,000 County of Hawaii Kilauea Recovery Grant $500,000 HFHHI Partner Family Sweat Equity $68,000 HFHHI Corporate Sponsor In-Kind Material Donations $8,500 HFHHI ReStore Revenue&Fund for Humanity Contribution $20,000 HFHHI In-Kind Land Donation $21,000 TOTAL: $667,500 Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: HFHHI continually seeks funding opportunities through governmental agencies and private foundations.HFHHI has developed a sustainable business model with our three ReStore locations,which collect and resell donated building materials and home furnishings.The ReStores generate around$1 million annually(pre-COVID),which covers operating costs and benefits our affordable housing programs.We also return a portion of partner families'mortgage payments to a revolving construction fund,called"The Fund for Humanity." At the time of writing,HFHHI is awaiting funding decisions from the County of Hawaii regarding HUD HOME funds ($900,000 requested),HUD SHOP funds($90,000)administered through Habitat for Humanity International(HFHI),and over$400,000 requested from private foundations.Our organization encourages the generosity of our individual donors throughout the year with fundraising campaigns—our donors give an average of$40,000 annually.Our 2020 Annual Ask Campaign brought in over$58,000 in donations. Other internal revenue sources include our network of volunteers—in 2019,volunteers contributed over$45,000 worth of labor on our construction sites. Partner families also contribute labor, called sweat equity,to their homes.Other sources of support come from our corporate sponsors in the form of donated building materials and supplies. HFHHI took part in administering the Rental &Mortgage Assistance Program(RMAP),which distributed$10 million to community members in need.This program earned our affiliate an 8%administration fee which will contribute to our mission of creating affordable housing here in Hawaii County. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of the"Nanawale Builds:Kilauea Recovery"program is to secure affordable housing for 5 families who were affected by the Kilauea eruption in 2018.Land and construction funding for 5 homes in Nanawale Estates have already been secured,and an offering has been developed and is being distributed to a list of victims of the eruption.County Nonprofit Grant Program Funds will be used for site development prior to construction,general requirements such as permits and inspections,volunteer appreciation efforts,and the allowed 10%of funding will cover overhead costs and approximately 125 hours wages for our Family Services Coordinator who will be screening applicants and working closely with our partner families throughout the program. Based on the average family size in Hawai'i County of 3.4,our Nanawale Builds program will help an average of 17 low-income individuals who were displaced by the Kilauea eruption to regain housing security.Many of the families we serve are single-parent households, households with young children,seniors,veterans,and people living with disabilities. By funding this program,the County addresses a 2020-2024 County Consolidated Plan high priority need-Affordable Housing-by supporting program activities that allow us to dedicate other funds to construction purposes. Funds from the County Nonprofit Grant program will NOT be used for any construction purposes or costs;rather County Nonprofit Grant funds will be used for site development and general site requirements(activities that support the development of affordable housing),and administration of the program,from family selection to closing.Remaining funds will be allocated for volunteer appreciation and personal protective equipment to keep our staff,volunteers,and partner families safe. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery B.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 5 Low-Income Families Transitioned into Safe,Decent,Affordable Housing New,Affordable Housing Units Made Available 5 Low-Income Individuals with Improved Housing Security(average based on 3.4 per household) 17 • 2500 Sweat Equity Hours Contributed by Program Beneficiaries(500 per household) Homeowner/Financial Education&Counseling Hours Completed 40 Partner Families with 10%Reduced Cost-Burden 5 Households Making Regular,On-Time Payments on Affordable,Interest-Free Mortgage 5 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $60,000 $2,500 Professional Fees Operations $50,000 $2,500 Supplies $75,000 Equipment $50,000 Other: Construction Materials $267,500 Other: General Requirements $12,500 $11,000 Other: Construction Subcontractor $50,000 Other: Volunteer Appreciation $2,500 $2,000 Other: Site Development $100,000 $32,0000 TOTAL $667,500 $50,000 *If applicable EXHIBIT A Page4of8 NONPROFIT GRANT APPLICATION FY 2021-2022 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:. Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery io0 ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): �I Q Member or members of the Council �I I� Staff appointed by a member of the Council H The Mayor The Managing Director '— The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • If no conflicts exist, check here. vsrov, 1/28/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Habitat for Humanity Hawai'i Island g y Program Name: Nanawale Builds: Kilauea Recovery 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 fit�Grant Application 7Y2021-22 • County of�awa� � Nonprofit' pp Agency Name: Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may resultin actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/28/2021 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Habitat for Humanity Hawai'i Island Program Name: Nanawale Builds: Kilauea Recovery 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Low-Income Families Transitioned into Safe, Decent, Affordable Housing 5 New, Affordable Housing Units Made Available 5 Low-Income Individuals with Improved Housing Security 17 Sweat Equity Hours Contributed by Program Beneficiaries 2,500 Homeowner/Financial Education & Counseling Hours Completed 40 Partner Families with 10% Reduced Cost-Burden 5 Households Making Regular, On-Time Payments on Affordable,Interest-Free Mortgage 5 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500 Professional Fees • Operations $2,500 Supplies Equipment Other: Construction Materials Other: General Site Requirements $11,000 Other: Construction Subcontractor Other: Volunteer Appreciation $2,000 Other: Site Development $32,000 TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hale Kupa, Inc. Kali Like Program 104 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hale Kipa, Inc. Program Name:Kai Like Program Agency Director: Ernest Pletan-Cross Phone No.:(808 ) 589 —1829 Contact Person: Jaque Kelley-Uyeoka Phone No.:(808 ) 589 —1829 Mailing Address: Address: 91-2128 Old Fort Weaver Road Address: City,sr,zip Ewa Beach, Hawaii 96706 Facility Address: Address: 622 Hinano Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: jaq@halekipa.org Fax No.: (808 ) 589 —2610 Accountant/CPA: Gwen Okamoto Phone No.:(808) 589 —1829 Firm (if applicable): Mailing Address: Address: 91-2128 Old Fort Weaver Road city,sr,zip Ewa Beach, Hawaii 96706 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 7,500 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna ❑■ Hamakua. ❑■ North Kona ❑■ South Hilo ❑ North Kohala ❑■ South Kona ❑■ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns El Youth ❑Victims of Crimes ❑� Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021=2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale Kipa, Inc. Program Name: Kai Like Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 2875 2.Agency Mission Statement: Hale Kipa provides opportunities and environment that strengthen and encourage youth,their families and communities to actualize their potential and social responsibility. 3. Program Description: Ka'i Like Program (KLP)Intensive Mentors(IM)work with Family Court-referred Youth and families by developing an individualized plan, linking youth and family to positive community resources, assist Youth in achieving educational goals and transporting Youth to necessary appointments. IMs are flexible in scheduling and have a"whatever it takes"attitude to see Youth succeed. KLP has a no-eject/reject policy and provides services to all Youth referred that agree to be involved in the program. IMs are also on-call 24/7 and provide emergency response to crisis. IMs advocate for Youth in Court and in treatment team meetings. • 4. Total Budget& Position Count: • Position Count:ram Total Program Budget: 216,000 Total Program 3 FTE Total Agency Budget: 8,246,000 Total Agency Position.Count: 108 FTE EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale Kipa, Inc. Program Name: Kai Like Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate DHS-Office of Youth Services(thru 6/30/21 w/10%cut,thereafter pending included in estimate) 180,000 Hawaii Island United Way (thru 6/30/21,thereafter pending included in estimate) 3,000 TOTAL: 183,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In addition to our Office of Youth Services funding,we received funding from Hawaii Island United Way and will apply to other grants and foundations as appropriate. • 7. Program Objectives Using County Nonprofit Grant Program Funds: Ka'i Like Program(KLP)plans to use these funds to assist our Youth and families in eliminating barriers for Youth to participate in different activities, access resources, reward Youth for positive behavior,and provide them with group activities across the island. Intensive Mentors(IM)will adjust in doing smaller group activities until larger group activities are permitted and safe. In previous experiences with KLP Youth,they often don't get to experience the cultural sites this • island has to offer and with the County's assistance,we will be able to provide our Youth with these experiences. Should COVID-19 prohibit group activities,we will explore cultural sites across the island in a one-on-one manner. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale Kipa, Inc. • Program Name: Kai Like Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) KLP Youth will not commit any new crimes 3-months post discharge. BO%of Youth discharged KLP Youth will improve academic performance. 80%of Youth enrolled Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 167,400 • Professional Fees 13,100 Operations 20;000 7,500 Supplies 500 Equipment 3,200 Other: Occupancy costs • 11,800 Other: Other: Other: Other: TOTAL 216,000 7,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hale Kipa, Inc. Program Name: Kai Like Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form.per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ® Member or members of the Council • Staff appointed by a member of the Council ® The Mayor ® The Managing Director II The Director of Finance ® The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Ev4.4 / Cfc) / l Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application . FY2021-22 Agency Name: Hale Kipa, Inc. Program Name: Kai Like Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale Kipa, Inc. Program Name: Kai Like Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any.funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 12- 6 Signature of Authorized Person Date Ernest Pletan-Cross, CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale Kipa, Inc. Program Name: Kai Like Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result KLP Youth will not commit any new crimes 3-months post discharge. 80%of Youth discharged KLP Youth will improve academic performance. 80%of Youth enrolled. TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations 7,500 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 7,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 ii Hale 0 Hawaii. Housing and Lands Enterprise of Hawai County Hale 0 Hawai'i Capacity Building 105 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Program Name:Hale 0 Hawaii Capacity Building Agency Director: Pete Hoffmann Phone No.:(808 )895 -0834 Contact Person: Pete Hoffmann Phone No.:(808 )895 -0834 Mailing Address: Address: 68-1783 Lua Kula Place Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: 68-1783 Lua Kula Place Address: City,ST,Zip Waikoloa, HI 96738 Email Address: petehoffmann@hawaii.rr.com Fax No.: ( ) - Accountant/CPA: Jennifer Scheel, BBA, PA Phone No.:(9C3 2.4t - CIS Firm (if applicable):Pacific Breeze Financial Mailing Address: Address: P.O. Box 385225 City,ST,Zip Waikoloa, HI 96738 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds:$31,000 Geographical Areas To Be Served: (One or more can be checked) Lo Puna 2Hamakua Q'North Kona 2/South Hilo [`North Kohala [✓South Kona R"North Hilo [1"1/South Kohala 1-131'Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns (— Youth n Victims of Crimes ❑ Culture and the arts PT/Aged [ictims of Health or Social Crises [+Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Program Name: Hale 0 Hawaii Capacity Building 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 n/a n/a n/a 2. Agency Mission Statement: The applicant, Housing and Land Enterprise of Hawaii County DBA Hale 0 Hawaii, is a 501(c)(3) nonprofit organization that is developing innovative solutions to Hawaii Island's affordable housing crisis, using a community land trust model. A community land trust is an entity organized to maintain the ownership of land, into perpetuity,for a specific, community- oriented purpose. It is designed to be a nontraditional form of property ownership,where the ownership of land is separated from the ownership of the above-ground improvements. The relationship between the entity that owns the land and the entity that owns the house on that land is defined by a "ground lease."A ground lease allows the cost of the home to be substantially lower, because the cost of the land is not included. A community land trust instills a clear social mission into the ground lease model:the entity that owns the land holds it in trust for a designated use—in this case, affordable housing—in perpetuity. Hale 0 Hawaii's long-term strategy is to secure and sustain a supply of affordable housing for low and moderate income residents of Hawaii Island. Each lease will be for a term of 99 years, renewable for an additional 99 years at a modest ground lease rent of$45/month. By taking land out of the speculative market,the community land trust model provides a viable pathway for perpetually affordable housing. However, homeowners will be able to receive a fair return on their investment upon resale,with a resale price set by a formula at the time of purchase.This approach ensures that future homebuyers will be able to access the home at an affordable orice. +1(Yea 0A 444124-r►malt- 3. Program Description: Hale o Hawaii is a 501(c)3 nonprofit organization formed in 2017,with a mission to secure and preserve a permanent supply of affordable housing alternatives for low and moderate income households in Hawaii County. The overarching vision of the program is to change lives by creating affordable housing through a community land trust model, one home at a time. The pool of residents that will be eligible for participation in the program include Hawaii Island residents who are USA citizens 18 years of age or older,with a household combined annual income that does not exceed 100%of the HUD median income of households of equal size residing in Hawaii County. Although only low or moderate income applicants are eligible, a minimum income and creditworthiness criteria are also part of the selection process.As this program grows and strengthens on Hawaii Island, many more struggling families will be provided with affordable homes and homebuyer/ homeowner education,which will serve to raise the quality of life for Hawaii Island residents. The specific project for which funding is herein requested is building capacity to enable our organization to expand its community outreach and operational capacities. Specific activities include: 1) Engaging a marketing officer to conduct educational sessions in the community to raise awareness about the concept of community land trust homeownership, program eligibility, homeowner rights and responsibilities, how to find the right mortgage and insurance, photovoltaic options,the Hale 0 Hawaii resale formula, and much more. Due to COVID-19 restrictions,we will initially hold virtual educational sessions, and will hold in-person events once restrictions on gatherings of more than 10 people have been lifted.The marketing officer will also oversee the planned website redesign that will create a robust platform for interaction with the community. 2) Our current website is static and fairly rudimentary.We will hire a professional website designer to improve and expand our web presence.The redesigned website will enable us to deliver better content in a more effective way an„d'augm our rrorlihility anti rnnnortinn to thin rnmmnnitt/w conio 'CO(t-hrued f1 t-ft'1ple' 4.Total Budget & Position Count: Total Program Budget: $35,500 Total Program Position Count: 2.5 Total Agency Budget: 4 50 n io '3% Total Agency Position Count: 2.5 TTAC EXHIBIT A �'-�-YV-C. 14-0\177 NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Agency Name: Program Name: Hale 0 Hawaii Capacity Building 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii FY21-22 funding request $31,000 In-kind Project Manager time S3,000 Hale 0 Hawaii operations (bookkeeping) $1,500 TOTAL: $35,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is a one-year capacity-raising project to allow us to better reach and engage with the community that we intend to serve and the funders who support our work.This project itself will not continue beyond the project period. However,from the perspective of overarching sustainability, Hale 0 Hawaii's model for developing affordable housing has a strategic integrated element for programmatic sustainability. Funds generated from the sale of every affordable home will be reinvested into a subsequent affordable home project,thus leveraging every grant and donation many times for exponential community benefit. In addition, it is well documented that donations and grants to community land trusts are successful at attracting additional funding in support of the affordable housing mission. One recent study regarding community land trusts for affordable housing in California found that each dollar donated to and spent by a community land trust has leveraged an additional seven dollars,while other studies nationwide have found that every dollar invested in a community land trusts for affordable housing will be leveraged up to 13 times, a powerful indicator of the potential impact of the requested grant funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: This project has three time-bound,specific and measurable objectives: 1. By the end of the project year, a part-time marketing officer will be hired to carry out community engagement activities and to oversee website development. 2. By the end of the project year, a minimum of seven educational events will be held. 3. By the end of the project year, a robust new website to better facilitate community engagement will be developed and launched. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Program Name: Hale 0 Hawaii Capacity Building 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES , (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,bespe specific.) Please refer to TABLE 1 in the application attachment. . Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages n/a $18,000 $15,000 Professional Fees $6,000 $6,000 Operations $1,500 Supplies $10,000 $10,000 Equipment _ Other: Other: Other: Other: Other: TOTAL $35,500 $31,000 if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Program Name:Hale 0 Hawaii Capacity Building so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): flMember or members of the Council IO Staff appointed by a member of the Council The Mayor OI The Managing Director II The Director of Finance U] The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 17/ If no conflicts exist, check here. � Qt, ✓L, D i R L C 1 o . 1-27-21 Signature of Authoriz ra Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Aplication FY2021-22 Hale 0 Hawaii: !dousing and Lands Enterprise of Hawaii County Agency Name: Program Name:Hale 0 Hawaii Capacity Building 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai`i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai`i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Program Name:Hale 0 Hawaii Capacity Building 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 40 v tir :. /Ve �-'� 1-27-2021 Signature of Authorized Perso Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hale 0 Hawaii: Housing and Lands Enterprise of Hawaii County Program Name: Hale 0 Hawaii Capacity Building 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Please refer to TABLE 1 in the application attachment. TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $15,000 Professional Fees $6,000 Operations Supplies $10,000 Equipment Other: Other: Other: Other: Other: TOTAL $31,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hale 0 H awa i Applicant: HALE 0 HAWAII HOUSING AND LAND ENTERPRISE OF HAWAII COUNTY APPLICATION ATTACHMENT 2. Agency Mission Statement (continued) By taking land out of the speculative market, the community land trust model provides a viable pathway for perpetually affordable housing. However, homeowners will be able to receive a fair return on their investment upon resale, with-a resale price set by a formula at the time of purchase. This approach ensures that future homebuyers will be able to access the home at an affordable price. The land trust approach to affordable housing is quite distinct from more conventional models such as the standard multiple dwelling unit project—for example, a 15-lot affordable housing subdivision. The land trust model focuses on selecting a property that has existing public infrastructure already in place (water, utilities, a public road). This unit-by-unit approach utilizing land with existing infrastructure serves to significantly reduce the cost of the finished product, whether newly built or remodeled. Hale 0 Hawaii is collaborating with the Habitat for Humanity and other affordable housing agencies to accomplish our mission to secure and preserve a permanent supply of affordable housing alternatives for low and moderate income households in Hawai'i County. Hale 0 Hawaii is also working with NAREIT Foundation, which provided $195,000 to purchase property in Hawaiian Paradise Park on which an affordable home will be constructed and made available through the land trust model, with priority to those who lost homes in the 2018 Kilauea eruption. A recent donation of two lots near Volcano Village will also be developed as land trust based affordable housing. Hale 0 Hawaii has an experienced and capable executive director and board of directors, with strong fiscal and administrative controls in place to properly manage the requested funds. Executive Director Pete Hoffmann has an extensive track record of successful stewardship of County and foundation funds and has served as the treasurer of Community Enterprises for the past ten years. During this time, he has provided oversight of County grants to that organization providing the necessary reports and management to County staff without any problems cited. The Board President, Michael Matsukawa, and two other Board members, Patrick Hurney and Loretta Wickenden, possess long experience complying with governmental mandates and risk management processes and will provide oversight of project activities on a continuous basis. Another Board Member, Phil Tinguely, has had years of experience working with the County on a variety of construction related projects, many utilizing County resources, and is well versed on the responsibilities and requirements regarding administrative and fiscal controls in this environment. All bookkeeping entries are supported by accompanying documents that are retained in the land trust files. A separate monthly report will be maintained as to the disposition of grant resources and will be reviewed by the full Board. 1 2021 Hawaii County NP Grant application attachment Applicant: HALE 0 HAWAII 3. Program Description (continued) 2) Our current website is static and fairly rudimentary. We will hire a professional website designer to improve and expand our web presence. The redesigned website will enable us to deliver better content in a more effective way and augment our credibility and connection to the community we serve. 3) Public outreach expenses, which include advertising, social media marketing, flyers that explain the community land trust approach, and other materials that support engaging with the community and raising public awareness about this opportunity for affordable homeownership. 8. TABLE 1: What are the measurable performance outcomes that would be achieved with this funding? Program Performance Outcomes Applicant Projected Results 1) The successful hiring of a well-qualified A marketing officer will be in place for the marketing officer who will be tasked with raising duration of this one-year project of raising community awareness about this affordable community awareness about land trust affordable homeownership opportunity, compiling a pool of homeownership. potential families who are interested in This outcome will be measured by the purchasing a home under the land trust concept, qualifications and capacities of the newly hired and assisting these families in applying for a marketing officer and an analysis of the return on mortgage. this marketing investment. 2) The successful presentation of at least seven Completed series of community engagement educational events. 0 sessions and analysis of compiled feedback from those sessions. These sessions will result in increased community awareness about our programs and the opportunities for affordable housing that we can offer. This outcome will be measured by measured by attendance logs and participant feedback surveys. 3) The successful development of an interactive A robust interactive website that will educate the website to facilitate community engagement. community about land trust homeownership, provide affordable home ownership opportunities, and answer questions about the process. Our community will be better educated about the community land trust based model for affordable housing and will have more confidence about looking further into this option for their `ohana. This outcome will be measured by standard key metrics for new website projects including initial data after launch (visitors, time on site, bounce rate, mouse tracking, keyword analysis, etc.) as well as feedback surveys from users. 2 2021 Hawaii County NP Grant application attachment Hiin akua Harvest, Inc. Demonstration Orchard at Hamakua Harvest, Inc. 106 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name: Demonstration Orchard at Hamakua Harvest, INC Agency Director: Jessica Sobocinski Phone No.: (808 ) 772 — 1269 Contact Person: Jessica Sobocinski Phone No.: (808 ) 772 — 1269 Mailing Address: Address: PO Box 621 Address: City,ST,Zip Honokaa,HI 96727 Facility Address: Address: 44-2600 Mamalahoa Hwy Address: City,ST,Zip Honokaa, HI 96727 Email Address: info@hamakuaharvest.org Fax No.: ( ) — Accountant/CPA: Carbonaro CPAs&Management Group Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $22,500 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona • North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ✓0 Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name: Demonstration Orchard at Hamakua Harvest, INC 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 17-18 FY 18-19 FY 19-20 $0 $8,675 $6,878 2.Agency Mission Statement: The mission of Hamakua Harvest, INC is to promote and advance agriculture by supporting local farmers, enriching the region's social fabric,and promoting healthy rural lifestyles for the benefit of Hamakau's communities, economy, and environment. 3. Program Description: Hamakua Harvest, Inc. (HH)is a 501(c)(3) non-profit organization based in Honoka'a on Hawai'i Island. Since 2015,the Farmer's Market at Hmkua Harvest in Honokaa has supported the consumption and production of local food, providing income and markets for agricultural businesses in the community while offering residents and visitors access to locally-grown and locally-crafted products. Our site also hosts an annual farmer training program(entitled Practical Agriculture for Hamakua),a Demonstration Orchard that pilots innovative orchard management techniques,and a Keiki Learning Garden where children from the Hamakua Youth Center engage in aina-based activities as part of their afterschool programming. As part of our strategy for promoting economic recovery and food security in our community, in 2021 the Demonstration Orchard at Hamakua Harvest is planning to partner with the Hawaiian Cultural Center of Hamakua(HCCOH)to integrate community garden plots into its operations and design this year to give local families a safe space and to grow food with the support and expertise of our Agricultural Programs Manager and staff of HCCOH.Additionally,the Demonstration Orchard and Farmers'Market will coordinate with Recycle Hawaii and community volunteers to build and maintain a small-scale composting operation that will divert biodegradable waste from the market and provide compost for the Demonstration Orchard and community garden plot projects.To help support the community garden plots and expand the food-growing capacity of the Demonstration Orchard,we want to install a small greenhouse to grow plant starts and propagate traditional Hawaiian crops. Outside of the community garden plots,the Demonstration Orchard will continue to donate a significant portion of its harvests of fruits and other edible plants to local feeding efforts.Additionally,our weekly farmers'market will be sponsoring weekly agriculture-related classes to promote agribusiness and home gardening, limiting class sizes to adhere to the County's COVID-19 gathering restrictions. 4.Total Budget&Position Count: Total Program Budget: $34,420 Total Program Position Count: $75,872 Total Agency Budget: 1 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name: Demonstration Orchard at Hamakua Harvest, INC 5. Program Funding Sources(identify all sources of funding applied to this program): FY20-21 Revenue Source Estimate Atherton Foundation Grant $7,690 Hawaii Community Foundation Grant $5,000 Donations $1,100 TOTAL: $13,790 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our organization's most consistent form of revenue are our vendor fees. In order to regrow market attendance, and therefore increase the average weekly number of vendors at the weekly farmers'market,we are incorporating more social-distanced seating options on-site and increasing our marketing efforts to attract both locals and visitors. Hamakua Harvest, INC will be purchasing additional merchandise with the organization logo as a way to both increase revenue and promote our programs. The organization will be soliciting donations on a quarterly basis as part of an ongoing fundraising campaign during 2021. While traditionally we have sold fruit and produce from our Demonstration Orchard as a way to generate minimal revenue,this year we will be donating most of this produce to local feeding efforts that support families who have been economically-impacted by the COVID-19 pandemic. However,the Demonstration Orchard could sell vegetable plant starts at the Farmers'Market if there is sufficient production in the nursery and doing so does not create competition with any existing nursery vendors. 7. Program Objectives Using County Nonprofit Grant Program Funds: The County Nonprofit Grant Program Funds will be used toward the implementation and ongoing management of community garden plots within the Demonstration Orchard, including the purchase of necessities such as garden tools, wooden signs, seeds, potting soil,fertilizer,and irrigation. Funds will also go towards staff time for the Agricultural Programs Manager to oversee the community garden plots program, provide instructional support to participants,and continue to grow and harvest food for donation to local feeding efforts.The Demonstration Orchard will also construct a greenhouse to grow and maintain a variety of food-bearing and culturally-significant plants for the community garden plots and other cultivated areas of the Demonstration Orchard.The funds will also support the purchase of tools and materials for the installation of an on-site community composting project in collaboration with Recycle Hawaii.These efforts will work synergistically to increase food production on our site,enabling us to provide more food to feeding efforts in our community, and increase food security in households across the Hamakua and North Hilo districts. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name:Demonstration Orchard at Hamakua Harvest, INC 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Pounds of produce from the Demonstration Orchard donated to local feeding efforts 100# Number of families/households managing community garden plots 10 families Number of food-bearing plant starts produced in the greenhouse sold at market 250 Pounds of finished compost generated from community compost 20# Attach additional pages as necessary. 9.TABLE II: FY 19-20 FY 20-21 FY 20-21 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $33,415 $35,150 $13,440 Professional Fees $2,000 $2,000 $0 Operations $2660 $10,692 $7,000 Supplies $512 $8,950 $0 Equipment $0 $1,000 $0 Other: Maintenance $7963 $12,480 $2,060 Other:Marketing $0 $400 $0 Other:Other Program Expenses $0 $5,200 $0 Other: Other: TOTAL $46,550 $75,872 $22,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name:Demonstration Orchard at Hamakua Harvest, INC 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist,check here. -NANO s20k5— - Board a-e5Vden� 01/28/2021 Si vir re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 5 of 8 Countyof Hawai`i Nonprofit Grant Application FY2020-21 p Agency Name: Hamakua Harvest, INC Program Name: Demonstration Orchard at Hamakua Harvest, INC 11.Certification of Understanding (Page J.of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. . If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Newel grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name:Demonstration Orchard at Hamakua Harvest, INC 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused by June 30, 2021 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Costs of Construction,materials,insurance or securities). By signing below,you are acknowledging that you have read and understood these requirements. — • 01 /28/2021 l - 0) rla.01, sign horized Person Date Baca PresixusTrk- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hamakua Harvest, INC Program Name:Demonstration Orchard at Hamakua Harvest, INC 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Pounds of produce from the Demonstration Orchard donated to local feeding efforts 100# Number of families/households managing community garden plots 10 families Number of food-bearing plant starts produced in the greenhouse sold at market 250 Pounds of finished compost generated from community compost 20# TABLE II: FY 20-21 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $13,440 Professional Fees $0 Operations $7,000 Supplies $0 Equipment $0 "Other: Maintenance $2,060 Other: Marketing $0 Other: Other Program Expenses $0 Other: Other: TOTAL $22,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HamakuEI Youth Foundation, Inc. I-Iamakua Youth Center 107 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hamakua Youth Foundation, Inc. Program Name:Hamakua Youth Center Agency Director: Teresa Sugg Phone No.:(808 ) 775 —0976 Contact Person: Lori Beach Phone No.:(80a) 775 —0976 Mailing Address:, Address: P.O. Box 381 Address: City,ST,Zip Honokaa, Hawaii 96727 Facility Address: Address: 45-3396 Mamane Street Address: City,sT,Zip Honokaa, Hawaii 96727 Email Address: hyclori9@gmail.com Fax No.: ( ) — Accountant/CPA: Schumacher Tax and Accounting Phone No.:(808) 345 —7900 Firm (if applicable): Mailing Address: Address: P.O. Box 395 City,ST,Zip Dewey, Arizona 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna 0 Hamakua ❑ North Kona ['South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ['Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application • FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21. $9,675 $9,925 $5,800 2.Agency Mission Statement: Our Vision is that Hamakua youth have access to unconditional support and guidance in life skills essential to their growth into kind,engaged,and inspired young adults.Our Mission is to open doorways to the world by sharing life skills rooted in the Hawaiian values of kuleana,aloha, laulima,and mahalo.Our programs engage these values--responsibility, love, cooperation and gratitude to cultivate the emotional, multicultural,and intellectual awareness necessary for Hamakua youth to thrive both here and beyond. KULEANA I Malama i kou kuleana Take care of your responsibilities ALOHA I Aloha kekahi i kekahi Love one another LAULIMA I E kuahui like i ka hana Let everyone work together MAHALO I Mahalo i ka mea loaa Be thankful for all that you have 0 3. Program Description: The Hamakua Youth Center(HYC)began serving youth in 1996 as an extension of the YWCA. In 2009,the Hamakua Youth Foundation, Inc. (HYF)was established as a 501(c)3 nonprofit organization to support HYC in a new phase of growth to create nurturing and dynamic youth-centered activities for youth from six to eighteen years of age.Over the years the HYC has maintained a network of partnerships with area organizations and schools to provide holistic year-round support to Hamakua Youth. The Hamakua Youth Center(HYC)provides safe,low cost,and enriching programs to high risk area youth.Our extracurricular programming blends academic learning and experiential life skills to enrich the lives of our students and their families. Elementary-aged children are provided with place-based multicultural learning opportunities,homework assistance,and experiential learning through agriculture,food preparation,arts and crafts and music.Our Teen Programs include advanced multicultural learning opportunities, internships,and access to three locally-supported scholarships for recent high school graduates. In response to the pandemic, HYF partnered with Vibrant Hawaii/Hawaii Rise Foundation to participate in the County of Hawaii CARES grant program.We expanded our community service programs and increased food security for families of enrolled youth,as well as elderly and persons with disabilities living between Kukuihaele and Laupahohoe. Currently,the Hamakua Youth Center is expanding with the recent purchase and renovation of the historic Okada Hospital.The renovated facility will provide a permanent home for our programs,triple the space of our current center, and allow HYF to greatly increase overall daily participation rates, including an expansion of programs for area teens. 4.Total Budget& Position Count: Total Program Budget: $103,885 Total Program Position Count: 6 Total Agency Budget: $205,900 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth'Center 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Secured Grant Income $20,900 Estimated Program Fees $11,280 Secured Donations $7,800 Unsecured Grant Income $43,805 Unsecured Donations $20,000 TOTAL: $103,885 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hamakua Youth Foundation recently purchased the historic Okada Building as our new facility,which is located next door to our current facility and across the street from the Honokaa School complex.This will triple the space we currently have and allow us to increase overall participation and expand the scope of programs to provide more alternatives for local teens.The new building offers two separate wings,one for the keiki programs(ages 12 and under)and the other for our expanded opio(ages 13 and older)programs.The area that connects the two wings will become a certified kitchen that will serve HYC as well as the entire community.There is also an apartment/office suite that can be leased out after renovations are complete. We are in the process of renovating this property which is expected to be completed by December 2021. Funds for the renovation are in place and these funds are being requested to help fund our on-going operations during this transition time.After the opening of our new facility,the increase in participation and the opportunity to rent out the certified kitchen, the apartment and other areas for community meeting spaces will increase revenues to support our programs. In addition to on-going grant opportunities,we promote three fundraising events each year that emphasis creation of long term benefactors to provide sustainability. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.To provide safe,nurturing, low-cost daily program for under-served youth ages 6-18. 2.To offer teens learning opportunities through internships and/or college practicums. 3.To strengthen life and leadership skills of our youth in a way that supports them making healthy choices,succeed in their academic studies and become kind,engaged,and inspired young adults. 4. To finalize a plan for an expanded teen program to become effective when we relocate to our new facility. 5. To complete the renovations to our new facility in order to open in 2022. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Maintain learning program for area youth as allowed under current situation* a)22 youth enrolled during DOE distance *Either(a)or(b)based on DOE distance or in-person learning b)40 youth enrolled during DOE in-person Engage teens in internship or mentorship programs. 2 to.20 teens engaged Define plan for new and expanded teen program Complete plan for teen program expansion Continue food assistance for enrolled families Food assistance for-110 individuals monthly Finalize the renovations to our new facility and open New Facility will be opened in 2022 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $61,111 $66,737 $14,340 Professional Fees $16,480 Operations $19,507 $2,500 Supplies $22,031 $8,200 $3,160 Equipment Other: Van expense $2,893 $4,641 Other: Food $1,492 $3,000 Other: Garden $2,237 $1,800 Other: Makahiki $4,225 Other: TOTAL $110,469 $103,885 $20,000 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii. Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): 0 Member or members of the Council Staff appointed by a member of the Council ® The Mayor O The Managing Director inThe Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: DI If no conflicts exist, check here. f1 Signature of Authorized PWri6n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6.of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and . accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms)on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Prion ate President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hamakuci Youth Foundation, Inc. Intersession Gardening Program 108 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program Agency Director: Teresa Sugg Phone No.:(808 ) 775 —0976 Contact Person: Lori Beach Phone No.:(801) 775 —0976 Mailing Address: Address: P.O. Box 381 Address: City,sr,zip Honokaa, Hawaii 96727 Facility Address: Address: 45-3396 Mamane Street Address: City,ST,Zip Honokaa, Hawaii 96727 Email Address: hyclori9@gmail.com Fax No.: ( ) - Accountant/CPA: Schumacher Tax and Accounting Phone No.:(808) 345 —7900 Firm (if applicable): Mailing Address: Address: P.O. Box 395 City,ST,Zip Dewey, Arizona 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Q Hamakua ❑ North Kona ❑South;Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑■ ■ Educational concerns Youth ❑ Victims❑ of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 _.Agency Name: Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $4,200 2.Agency Mission Statement: Our Vision is that Hamakua youth have access to unconditional support and guidance in life skills essential to their growth into kind,engaged,and inspired young adults.Our Mission is to open doorways to the world by sharing life skills rooted in the Hawaiian values of kuleana, aloha, laulima,and mahalo. Our programs engage these values-- responsibility, love,cooperation and gratitude to cultivate the emotional, multicultural,and intellectual awareness necessary for Hamakua youth to thrive both here and beyond. KULEANA I Malama i kou kuleana Take care of your responsibilities ALOHA I Aloha kekahi i kekahi Love one another LAULIMA I E kuahui like i ka hana Let everyone work together MAHALO I Mahalo i ka mea loaa • Be thankful for all that you have 3. Program Description: Hamakua Youth Center provides intersession programs for area youth,ages 6 to 18, during regularly scheduled closures of the Honokaa Schools complex.These sessions emphasize experiential, hands-on learning that begins at our Keiki Garden and expands from mauka to makai as we share important lessons in environmental kinship, land stewardship, growing practices,and foodways. Malama aina is central to our intersession programs that establish Hawaiian wisdom and connection to place as the foundation upon which our multi-ethnic community lives and thrives.This is reflected in our mala where our primary crops are ancestral and the living kinolau of Na Akua Eha,or four central gods.We grow kalo, uala,ulu,maia, loulu,niu,olena, kukui, ko,and ki,as well as a few non-traditional and forest plants such as waipini and hapuu.We follow ancestral planting,growing,and harvesting practices,guided by Na Helu Po.Our lessons are grounded in the manao of aloha aku, aloha mai a me kokua aku, kokua mai-recognize and be recognized, help and be helped. In sharing these practices of environmental kinship,youth develop a deeper appreciation of aina and connection to these kupuna who sustain our past, present,and future. Four sessions are scheduled to be hosted during the project period,including two weeks in July 2021,fall break 2021, spring break 2022,and June 2022.Approximately 15 to 20 youth will be served in each session,with priority given to elementary-aged youth from low-and moderate-income families.Youth living between Kukuihaela and Laupahoehoe are invited to participate. 4.Total Budget& Position Count: Total Program Budget: $103,885 Total Program Position Count: 4 Total Agency Budget: $205,900 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Secured Grant Income $20,900 Estimated Program Fees $11,280 Secured Donations $7,800 Unsecured Grant Income $43,805 Unsecured Donations $20,000 TOTAL: $103,855 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hamakua Youth Foundation recently purchased the historic Okada Building as our new facility,which is located next door to our current facility and across the street from the Honokaa School complex. This will triple the space we currently have and allow us to increase overall participation and expand the scope of programs to provide more alternatives for local teens. The new building offers two separate wings,one for the keiki programs(ages 12 and under)and the other for our expanded opio(ages 13 and older)programs. The area that connects the two wings will become a certified kitchen that will serve HYC as well as the entire community.There is also an apartment/office suite that can be leased out after renovations are complete. We are in the process of renovating this property which is expected to be completed by December 2021. Funds for the renovation are in place and these funds are being requested to help fund our Intersession Program during this transition time.After the opening of our new facility,the increase in participation and the opportunity to rent out the certified kitchen, the apartment and other areas for community meeting spaces will increase revenues to support our programs. In addition to on-going grant opportunities,we promote three fundraising events each year that emphasis creation of long term benefactors to provide sustainability. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Applied Learning: Hands-on,experiential learning on-site at our Keiki Garden and off-site in the Hamakua district, as allowed by federal,state,and county COVID safety procedures. 2. Hawaiian Cultural Learning:Create Hawaiian culture learning opportunities,with emphasis on environmental kinship and growing practices. 3.Ahupuaa Learning:Create place-based, mauka to makai learning opportunities that emphasize the interconnected ecosystems of Hamakua. 4. Leadership Development: Provide leadership development opportunities grounded in Hawaiian culture. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 1.Intersession programs 2 two-week summer sessions 2 one-week fall/spring sessions 2.Intersession enrollment 15+youth enrolled each session(60+total) 3.Applied learning 80%of program off site(garden,field trips) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $61,111 $66,737 $6,400 Professional Fees $16,480 Operations $19,507 Supplies $22,031 $8,200 $1,000 Equipment Other: Van Expense $2,883 $4,641 $300 Other: Food $1,492 $3,000 $500 Other: Garden $2,237 $1,800 $1,800 Other: Makahiki $4,225 Other: TOTAL $110,469 $103,885 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 0 Member or members of the Council ® Staff appointed by a member of the Council Mayor The Ma ® Y • The Managing Director • The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. p //z 7/2_ Signature of Authorized Per (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: intersession Gardening Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement • to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Pevg ate President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Intersession Gardening Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM'EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HamakuEl Youth Foundation, Inc. Keiki Multicultural Awareness Program 109 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hamakua Youth Foundation, Inc. Program Name:Keiki Multicultural Awareness Program Agency Director: Teresa Sugg Phone No.:(808 ) 775 —0976 Contact Person: Lori Beach Phone No.:(808) 775 —0976 Mailing Address: Address: P.O. Box 381 Address: City,ST,Zip Honokaa, Hawaii 96727 Facility Address: Address: 45-3396 Mamane Street Address: City,ST,Zip Honokaa, Hawaii 96727 Email Address: hyclori9@gmail.com Fax No.: ( ) - Accountant/CPA: Schumacher Tax and Accounting Phone No.:(808) 345 —7900 Firm (if applicable): Mailing Address: Address: P.O. Box 395 City,sr,Zip Dewey, Arizona 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑■ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) E Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Keiki Multicultural Awareness Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5.925 $4,625 $3,800 2.Agency Mission Statement: Our Vision is that Hamakua youth have access to unconditional support and guidance in life skills essential to their growth into kind,engaged,and inspired young adults.Our Mission is to open doorways to the world by sharing life skills rooted in the Hawaiian values of kuleana,aloha, laulima,and mahalo. Our programs engage these values--responsibility, love,cooperation and gratitude to cultivate the emotional, multicultural,and intellectual awareness necessary for Hamakua youth to thrive both here and beyond. KULEANA I Malama i kou kuleana Take care of your responsibilities ALOHA I Aloha kekahi i kekahi Love one another LAULIMA I E kuahui like i ka hana Let everyone work together MAHALO I Mahalo i ka mea loaa Be thankful for all that you have 1111 3. Program Description: Our Keiki Programs are open to youth ages 12 and under. During the school year we serve keiki from Honokaa _ Elementary School. Each day our staff escort students the half block from the school to HYC and provide in-town rides home at the end of the day. Due to COVID-19, HYC is currently providing full-day programming for keiki in a safe and caring environment.Youth receive support with distance learning as well as enrichment in activities such as music,art, and gardening. HYC will return to after school programming once the Department of Education resumes in-person schooling for Honokaa Elementary School students. All keiki programs are rooted in learning Hawaiian values,stories,and basic language. From this place of strength,our keiki begin to explore the multicultural community of Haamakua through food and history.Activities include homework help,growing and preparing food,arts and crafts(lei-making,ceramics,painting,etc), music,STEM exploration,and field trips. Low-income status,family size and composition are self-certified by families as part of our registration process. For the spring semester,36 youth are enrolled with 22 and 14 receiving in-person and remote support, respectively. Eighty-three percent of HYC enrolled youth are from low and moderate income households(based on 2020 federal HUD thresholds) and 11%chose not to report income. HYC also believes that the health of youth depends on the health of families and,to support the holistic needs of Hamakua youth,we provide food assistance to enrolled in-person families, enrolled remote families,the elderly,and persons with disabilities living between Kukuihaele and Laupahoehoe(-.110-180 served per month)_Approximately 83%of elderly and persons with disabilities receiving food assistance are self-reported recipients 4.Total Budget& Position Count: Total Program Budget: $103,885 Total Program Position Count: 4 Total Agency Budget: $205,900 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Keiki Multicultural Awareness Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Secured Grant Income $20,900 Estimated Program Fees $11,280 Secured Donations $7,800 Unsecured Grant Income $43,805 Unsecured Donations $20,000 TOTAL: $103,885 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hamakua Youth Foundation recently purchased the historic Okada Building as our new facility,which is located next door to our current facility and across the street from the Honokaa School complex.This will triple the space we currently have and allow us to increase overall participation and expand the scope of programs to provide more alternatives for local teens.The new building offers two separate wings,one for the keiki programs(ages 12 and under)and the other for our expanded opio(ages 13 and older)programs.The area that connects the two wings will become a certified kitchen that will serve HYC as well as the entire community.There is also an apartment/office suite that can be leased out after renovations are complete. We are in the process of renovating this property which is expected to be completed by December 2021.Funds for the renovation are in place and these funds are being requested to help fund our Keiki Program during this transition time. After the opening of our new facility,the increase in participation and the opportunity to rent out the certified kitchen,the apartment and other areas for community meeting spaces will increase revenues to support our programs. In addition to on-going grant opportunities,we promote three fundraising events each year that emphasis creation of long term benefactors to provide sustainability. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Educational Support: Provide learning support for youth ages six to twelve with emphasis on low/moderate income youth and/or children of essential workers. 2.Hawaiian Cultural Learning:Create Hawaiian culture learning opportunities,with emphasis on environmental kinship and growing practices. 3.Multicultural Learning:Create an awareness of the many cultures that contribute to life in Hamakua,with emphasis on customs and foodways. 4. Direct Food Assistance: Provide enrolled families with culturally relevant produce baskets and family meal bags once per month in alignment wih our Hawaiian cultural and multicultural curricula. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application . FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Keiki Multicultural Awareness Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 1.Distance learning support during DOE distance learning(#1 OR#2) 22 in-person and 14 remote enrolled 2.After school learning support during DOE in-person learning(#1 OR#2) 35 youth enrolled 3.Hawaiian cultural lessons 6 units during AY21-22 4.Multicultural lessons 4 units during AY21-22 5.Family day 1-2 family events in AY21-22* *In accordance with COVID safety • 6.Direct food assistance for enrolled families 110+individuals served monthly in AY21-22 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $61,111 $66,737 $14,340 Professional Fees $16,480 Operations $19,507 $2,500 Supplies $22,031 $8,200 $3,160 Equipment Other: Van Expense $2,893 $4,641 Other: Food $1,492 $3,000 Other: Garden $2,237 $1,800 Other: Makahiki $4,225 Other: TOTAL $110,469 $103,885 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name:Keiki Multicultural Awareness Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor [0] The Managing Director flThe Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. 11/2,64,4 27/2_, Signature of Authorized Perforc (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 n County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name:Keiki Multicultural Awareness Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name:Keiki Multicultural Awareness Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 7:4_,Ag cugxv Signature of Authorized Pero i Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name:Keiki Multicultural Awareness Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HHamakuEI Youth Foundation, Inc. Opio (Teen) Program 110 County of Hawai`i Nonprofit Grant Application. FY2021-22 Agency Name:Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program Agency Director: Teresa Sugg Phone No.:(808 ) 775 —0976 Contact Person: Lori Beach Phone No.:(80a) 775 —0976 Mailing Address: Address: P.O. Box 381 Address: City,ST,Zip Honokaa, Hawaii 96727 Facility Address: Address: 45-3396 Mamane Street Address: City,ST,Zip Honokaa, Hawaii 96727 Email Address: hyclori9@gmail.com Fax No.: ( ) — Accountant/CPA: Schumacher Tax and Accounting . Phone No.:(808) 345 —7900 Firm (if applicable): Mailing Address: Address: P.O. Box 395 city,sr,Zip Dewey, Arizona 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑■ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged -❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 L - - County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $7,350 $4,875 2.Agency Mission Statement: Our Vision is that Hamakua youth have access to unconditional support and guidance in life skills essential to their growth into kind,engaged,and inspired young adults.Our Mission is to open doorways to the world by sharing life skills rooted in the Hawaiian values of kuleana,aloha, laulima,and mahalo. Our programs engage these values-- responsibility,love,cooperation and gratitude to cultivate the emotional, multicultural,and intellectual awareness necessary for Hamakua youth to thrive both here and beyond. KULEANA I Malama i kou kuleana Take care of your responsibilities ALOHA I Aloha kekahi i kekahi Love one another LAULIMA I E kuahui like i ka hana Let everyone work together MAHALO I Mahalo i ka mea loaa Be thankful for all that you have 0 3. Program Description: Our•Opio Programs are open during the school year to youth ages 13 and over who attend Honokaa High and Intermediate School or Laupahoehoe Public Charter School.The Hamakua Youth Center is currently undergoing a large capital improvement project that will include a teen center in the renovation of the historic Okada Hospital.This separate space just for teens will enable the expansion of the HYC Opio Programs. Currently,in partnership with the Ko Education Center(formerly NHERC), HYC offers internship and practicum opportunities to area teens and college students interested in learning about work in nonprofits,youth programming,and applied skills such as website design and social media outreach. In collaboration with Honokaa High and Intermediate School, HYC engages youth in leadership development and community service programs. Lastly, in partnership with local donors, HYC offers three scholarships to recent graduates of Honokaa High and Laupahoehoe Public Charter schools. In advance of opening our new center, HYC will begin to scale and finalize the expansion plan for our existing Opio Programs.Our goal is to provide teens with leadership development opportunities and advanced lessons in Hawaiian culture and multicultural awareness.Alongside these opportunities,our Opio programs will create space for teens to explore their identities,passions,and dreams for the future as they prepare to transition into adulthood. 4.Total Budget& Position Count: Total Program Budget: $103,885 Total Program Position Count: 4 Total Agency Budget: $205,900 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Secured Grant Income $20,900 Estimated Program Fees $11,280 Secured Donations $7,800 Unsecured Grant Income $43,805 Unsecured Donations $20,000 TOTAL: $103,885 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hamakua Youth Foundation recently purchased the historic Okada Building as our new facility,which is located next door to our current facility and across the street from the Honokaa School complex.This will triple the space we currently have and allow us to increase overall participation and expand the scope of programs to provide more alternatives for local teens.The new building offers two separate wings,one for the keiki programs(ages 12 and under)and the other for our expanded opio(ages 13 and older)programs.The area that connects the two wings will become a certified kitchen that will serve HYC as well as the entire community.There is also an apartment/office suite that can be leased out after renovations are complete. We are in the process of renovating this property which is expected to be completed by December 2021. Funds for the renovation are in place and these funds are being requested to help fund our Opio Program during this transition time. After the opening of our new facility,the increase in participation and the opportunity to rent out the certified kitchen,the apartment and other areas for community meeting spaces will increase revenues to support our programs. In addition to on-going grant opportunities,we promote three fundraising events each year that emphasis creation of long term benefactors to provide sustainability. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Applied Learning:Offer applied learning opportunities through internships and/or college practicums,with special emphasis on youth programming,agriculture,and nonprofit sectors. 2.Opio to Keiki Mentorship:Provide community service opportunities for teens to mentor elementary-aged youth after school. 3. Leadership Development: Provide leadership development opportunities grounded in Hawaiian culture. 4. Program expansion plan:Scale and finalize plan for 2022 expansion of Opio Programs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022; Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 1.Applied Internships and/or Practicums 2-3 participants per year 2.Opio to Keiki Mentorship Program 10 to 20 teens enrolled 100 Opio to Keiki mentoring hours 3. Leadership Development 4 leadership development workshops 4.2022 Opio Program explansion plan Expansion plan with five-year strategic goals Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $61,111 $66,737 $7,170 Professional Fees $16,480 Operations $19,507 $1,250 Supplies $22,031 $8,200 $1,580 Equipment Other: Van Expense $2,893 $4,641 Other: Food $1,492 $3,000 Other: Garden $2,237 $1,800 Other: Makahiki $4,225 Other: TOTAL $110,469 $103,885 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ® Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ro The Managing Director El The Director of Finance El The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Pers1n specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. -7-e-72f=aq / /a/z/ Signature of Authorized PI' fsdn g Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Opio (Teen) Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawaii Children's Action Network (HCAN) Hawai'i Diaper Bank (a fiscally sponsored program of HCAN) 111 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network (HCAN) Program Name:Hawaii Diaper Bank(a fiscally sponsored program of HCAN) Agency Director: Deborah Zysman Phone No.:(808 ) 342 —7452 Contact Person: Jessica Histo Phone No.:(808 ) 731 —6611 Mailing Address: Address: P.O. Box 2044 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 65-1204 Lindsey Road Address: Suite A City,ST,Zip Kamuela, HI 96743 Email Address: jessica@hawaiidiaperbank.org Fax No.: ( ) — Accountant/CPA: Joseph Evans,Hawaii Children's Action Network,CFO Phone No.:(808 ) 531 —5502 Firm (if applicable): Mailing Address: Address: 850 Richards Street Suite 201 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna ❑� Hamakua ❑■ North Kona D South Hilo ■❑ North Kohala ❑ South Kona ❑ North Hilo El South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ■❑Youth Victims of Crimes D Culture and the arts ❑Aged ❑■ Victims of Health or Social Crises ❑l Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank(a fiscally sponsored program of HCAN) n 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A $5,625 2.Agency Mission Statement: Founded in 2016, Hawaii Diaper Bank's(HDB)mission is to serve and support the keiki of Hawaii by providing diapers, wipes, and other essentials to organizations that assist low-income families with young children. We are committed to eliminating diaper need for the 1 in 3 families that experience its detrimental effects. We are a fiscally sponsored project*of the Hawai'i Children's Action Network(HCAN), a 501(c)(3) nonprofit organization that advocates for the safety, health, and education of Hawaii's children. HDB is the first diaper bank in the State of Hawaii and the only diaper bank on Hawaii Island, and believe that all children deserve access to clean, dry diapers which improves the physical, mental, and economic well-being of babies, families, and communities. *As a fiscally sponsored project, HDB has the same legal and tax-exempt status as HCAN. For more information about our relationship with HCAN, please see attached"Agreement for Fiscal Sponsorship Services". 3. Program Description: HDB distributes diapers, wipes, and other basic essentials through 13 community organizations("partners"), who in turn provide additional services, support, and resources. Our partners may make monthly bulk requests for diapers and wipes or special requests for Makana Packs. Makana Packs are for special occasions(like birthdays or the birth of a new baby) and include diapers,wipes, blankets, books, clothing, hygiene products, and toys.As one can imagine,the need for our services has dramatically increased during the pandemic.To better serve our community during this public health emergency,we have also formed a temporary partnership with The Salvation Army(TSA), Hilo Temple Corp office and expanded our services providing diapers and wipes to children on Moloka'i. Last fiscal year,2019-2020,we distributed more than 200,000 donations 155 Makana Packs, serving an average of 153 children per month. Since July 1st,2020 we have already distributed over 291,000 donations,533 makana packs and are serving an average of 451 children per month.Without our services, many of our partners would need to use their limited funds to purchase diapers and wipes for families and children under their care. Our partners report that, with our donations,they are able to increase program enrollment and/or attendance,to build rapport with families and our community, and provide economic stability for families served. Unlike other important resources,there is currently no federal or state assistance for purchasing diapers.As a result,the average low-income family pays$1,000 a year for diapers. Our donations help parents close the"diaper gap"(i.e., the difference between the number of diapers needed, and the number of diapers parents can afford to provide), lessening the risk of urinary tract infections,diaper dermatitis, and other infections. Once diaper need is alleviated, parents can tackle other issues such as, how to pay rent and utilities, how to get food on the table, and how to support the healthy development of their child/children. 4. Total Budget & Position Count: Total Program Budget: $215,00 Total Program Position Count: 1.5FTE-paidNolunteer Total Agency Budget: $963,519 Total Agency Position Count: 6 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank(a fiscally sponsored program of HCAN) 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate 1. Grants& Foundations $100,000 2. Government Grants $25,000 3. Corporate Donations $15,000 _ 4. Individual Donors $50,000 5. Other : Events $25,000 TOTAL: $215,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In the wake of the effects of COVID-19 like many other organizations we cancelled our annual fundraising event and have instead focused our efforts on socially distanced community engagement. Six new drop-off locations were secured(we now have 16 all over the island). The promotion of our Amazon Wishlist and added donation drives have resulted in an increase in donations of diapers wipes, and other basic essentials.As a result, instead of spending money on these items, we were able to allocate funds toward operational expenses, which has improved our efficiency and impact. This fiscal year, we have received an increase of cash donations from various community,corporate and individual donors. Furthermore,the number of individual monthly donors has significantly increased. We plan to continue building relationships and raising awareness within the community in an effort to continue to receive an increase in donations. Our Auntie Ambassadors which act as an auxiliary board have also held their own drives or fundraisers on our behalf, and we have just added our first group of Uncle Ambassadors. We plan to continue to increase and expand our community presence through the Auntie and Uncle Ambassadors, in order to increase revenues and donations in the coming year. We are fortunate to be part of the National Diaper Bank Network and Baby2Baby National Network, which affords us the opportunity to apply for grant funding, as well as additional in-kind support. Lastly, we aim to hold our first virtual event in early 2021 to help raise additional funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objective is to elevate HDB's community presence, raise diaper need awareness, and increase HDB's operational efficiency. Funds from this grant would be used to pay our fiscal sponsorship fee listed under(Professional fees), renew the lease to our first office/storage space and continue to compensate our president for at least a portion of time that she puts into our organization. During the first month of the pandemic our referrals tripled, and to better serve the urgent needs of our community,we began making bulk diaper and wipe purchases for the very first time. Our office/storage space provides 8 times as much space for inventory than our previous space, the private residence of our President. With more space for inventory,we are able to fulfill monthly orders more quickly. The new space also acts as a drop-off location for donations. Furthermore, because of our increased visibility from the new space, we conducted several more donation drives. In November and December alone,we received over 30,000 diapers, wipes, hygiene products, books,toys, blankets, and clothes.To ensure we continue to have a big impact in our community, it is imperative we renew the lease of our office/storage space.Additionally, as we continue to grow, it is important we continue compensating our hard-working president in the same manner as contemplated by our 2020-2021 fiscal year grant. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank(a fiscally sponsored program of HCAN) 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 1. Number of partnerships estaaablished and maintained 25 Partnerships 2. Number of clients to receive diapers, wipes and/or other basic essentials 1,500 Children 3. Number of diapers,wipes and other basic essentials collected 500,000 Donations 4. Increase the number of volunteer hours(not including president and board chair) 1,000 Logged Volunteer Hours Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req q Salary and Wages $15,000 $30,000 $12,500 Professional Fees $13,400 $28,450 $2,500 Operations $0 $0 $0 Supplies $4,500 $5,500 $0 Equipment $4,750 $7,000 $0 Other: Rent $24,000 $30,000 $10,000 Other: Utilities, Telephone & Internet $1,500 $3,000 $0 Other: Cleaning & Maintenance $900 $1,200 $0 Other: Unforseen Expenses $1,000 $18,350 $0 Other: Program Supplies (Diapers, Wipes, Essentials) $34,950 $91,500 $0 TOTAL $100,000 $215,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network Hawai'i Diaper Bank(a fiscally sponsored program of HCAN) Program Name: io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): • Member or members of the Council Staff appointed by a member of the Council ® The Mayor In The Managing Director in The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. ,4011 4k Vice President and Executive Director 1/20/21 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank(a fiscally sponsored program of HCAN) 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawai'i Children's Action Network (HCAN) Hawaii Diaper Bank(a fiscally sponsored program of Hawai'i Children's Action Network) Program Name: ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ... . . „goAvir -oft,. 1/20/2021 Signature of Authorized Person Date Vice President and Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank(a fiscally sponsored program of HCAN) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1.Number of partnerships established and maintained 25 Parnerships 2. Number of clients to receive diapers, wipes and/or other basic essentials 1,500 Children 3. Number of diapers, wipes and other basic essentials collected 500,000 Donations 4. Increase number of volunteer hours(not including president and board chair) 1,000 Logged Hours TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $12,500 Professional Fees $2,500 Operations $0 Supplies $0 Equipment $0 Rent1 r Other: $ 0 000 Other: Utilities, Telephone & Internet $0 Other: Cleaning & Maintenance $0 Other: Unforseen Expenses $0 Other: Program Supplies(diapers,wipes,essentials) $0 TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Havvai'i County Economic Opportunity/ Council East Hawaii Nutrition Transportation 112 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Havvai`i Nutrition Transportation Agency Director: Chad Hasegawa Phone No.: (808) 961— 2681 Contact Person: Chad Hasegawa Phone No.: (808)961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Email Address: hceocwriter@hceoc.net Fax No.: (808)961 —2812 Accountant/CPA: Phone No.: (808) 930— 6850 Firm (if applicable): Carbonaro CPAs &Management Company Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $195,469.59 Geographical.Areas To Be Served: (One or more can be checked) ® Puna ❑ Hamakua [' North Kona 111 South Hilo ❑ North Kohala ❑South Kona j North Hilo ❑South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns U Youth ❑Victims of Crimes ❑ Culture and the arts n Aged ❑Victims of Health or Social Crises E Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Nawai`i Nutrition Transportation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $11,375 2.Agency Mission Statement: HCEOC's mission is to reduce,mitigate and alleviate poverty. HCEOC is a private non-profit organization established in 1965. It qualifies as a Community Action Agency(CAA) governed by a 12 member tri-partite Board of Directors, equally representing public, private and low-income community members. HCEOC mobilizes public and private resources to assist low-income households, seniors and individuals with disabilities who face multiple barriers due to poverty. Its goal is to enable them to become more self-sufficient and enjoy a higher quality of life through programs and services that reduce,mitigate and alleviate the impacts of poverty in Ha.wai`i County. 3. Program Description: No hungry seniors on Hawai`i Island are the fundamental purpose of HCEOC`s Nutrition Transportation program.An estimated 22% of Hawai`i County's population is 65 years or older. A majority of seniors are living on a fixed income while managing the increased cost of living, health care expenses and COVID-19 related issues.The county has an estimated 12%of seniors who are living below the poverty level. AccessH1 Transportation Program transports low-income seniors (65+) with limited or no transportation access to congregate meal sites (has been canceled due to COVID-19), grocery stores and farmers' markets. Clients are picked up at home,taken to county nutrition sites,grocery stores and/or farmers'markets then return home at no cost. While HCEOC has a County of Hawai`i contract for nutrition transportation, the funds are not enough to cover the cost of operations throughout the fiscal year. For example, the actual cost per trip is$12 but HCEOC receives only $7.25 from its contracts and is forced to cover the overage through other funding sources. 4.Total Budget& Position Count: Total Program Budget: $332,284.30 Total Program Position Count: 11 Total.Agency Budget: $4,563,598.86 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Nutrition Transportation 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate. County ofHawai`i Office of Aging $136,843.00 Hawai`i Island.United Way AccessHl Seniors Transportation-Island Wide $9,500.00 TOTAL: $146,343.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is currently working on expanding the agency's fundraising efforts. HCEOC is conducting a trial monthly fundraiser.HCEOC is also working on increasing their social media presence on Facebook and Instagram in order to begin the fundraising efforts.It is exploring new innovative methods to raise funds for the transportation programs and the agency's other programs. Throughout the fiscal year,HCEOC continues to search and apply for government and foundation grants that address the transportation needs of the community. In June 2020,HCEOC was awarded a two-year grant from the Hawaii Island United Way for the transportation program to transport seniors to farmers'markets, grocery stores, medical sites, social, community or cultural activities. HCEOC has partnered withother community human services organizations to provide transportation for their clientele: By working together, HCEOC and the other agencies are able to achieve their goals in assisting members of the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the program is to improve the quality of life for seniors and individuals with disabilities in East Hawai`i(North and South Hilo,Puna and Ka`u)to have transportation to access nutrition programs including Seniors Farmers'Market. Objective 1: Provide transportation to 300 seniors(65+years old) and individuals with disabilities residing in East Hawai`i to nutrition sites and Seniors Farmers'Market sites. To accomplish this objective, HCEOC will dedicate three drivers and three vans to serve East Hawai`i.We will collaborate with County Nutrition sites and Seniors Farmers'Market sites in East Hawai`i communities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Nutrition Trans sortation 8.TABLE I: • What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Enroll low-income seniors(65+years old)and individuals with disabilities 300 individuals Provide transportation to nutrition sites,seniors farmers'markets and grocery stores(unit is one way transport) 6000 units Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $220,732.47 .$85,239.31 $135,493.16 Professional Fees $25,524.16 $9253.13 $16,271.03 Operations $85,556.71 $41,851.31 $43,705.40 Supplies $470.96 $500.00 Equipment Other: Other: Other: Other: Other: • TOTAL $332,284.30 $136,843.75 $195,469.59 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name:East Hawai`i Nutrition Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless,of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): n Member or members of the Council (i Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance I I The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ))1 qrg{ Signature of Authorize.'.•erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application. FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Nutrition Transportation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving.payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Nutrition Transportation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai`i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www,hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except fora maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 2 „ /0.-n Signature of Authorize Person Date Executive Director. Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Havvai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Nutrition Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Enroll low-income seniors(65+years old)and individuals with disabilities 300 individuals Provide transportation to nutrition sites,seniors farmers'markets and 6000 units grocery stores(unit is one way transport) TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $135,493.16 Professional Fees $16,271.03 Operations _ $43,705.40 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $195,469.59 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawail County [Economic Opportunity Council East Hawaii Seniors Farmers' Market 113 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Seniors Farmers' Market Agency Director: Chad Hasegawa Phone No.: (808)961 — 2681 Contact Person: Chad Hasegawa Phone No.: (808)961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Email Address: hceocwriter@hceoc.net Fax No.: (808)961 —2812 Accountant/CPA: Phone No.: (808)930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Company Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION.CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $37,784.75 Geographical Areas To Be Served: (One or more can be checked) ® Puna [ Hamakua [ North Kona 0 South Hilo ❑ North Kohala ❑South Kona [North Hilo ❑South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts I)Aged ❑Victims of Health or Social Crises 0 Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East H'awai`i Seniors Farmers' Market 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $14,500 2.Agency Mission Statement: HCEOC's mission is to reduce, mitigate and alleviate poverty.HCEOC is a private non-profit organization established in 1965.. It qualifies as a Community Action Agency (CAA) governed by a 12 member tri-partite Board of Directors, equally representing public, private and low-income community members. HCEOC mobilizes public and private resources to assist low-income households, seniors and individuals with disabilities. its goals is to enable them to become more self-sufficient and enjoy a higher quality of life through programs and services that reduce,mitigate and alleviate the impacts of poverty in Hawaii County. 3. Program Description: Healthy food means healthy seniors. Seniors Farmers'Market provides low-income seniors (65+ years old) with a coupon book with 10 five dollar coupons to purchase fresh produce at farmers' markets. With this program, HCEOC will provide coupons and transportation to the Food Basket Mobile Market and Da Box distribution sites for qualified seniors. Currently,the Seniors Farmers' Market funding provides coupons from April-September.Through this project, staff will conduct outreach and enrollment events. Staff will also work with Farmers'Market, Food Basket and Da Box to ensure seniors have access to fresh produce. The target population to be served is a minimum of 600 low-income seniors (65+) individuals residing in East Ramiei which includes North and South Hilo, Puna, and Ka`u. Currently,the State of Hawai`i Office of Community Services provides $69,404.95 to administer the program on Hawaii Island. A majority of the funds (93%) is allocated directly to coupons. The remaining funds is allocated to administrative cost.This proposal will provide additional funds to increase distribution of applications to seniors across the island for a full year. 4.Total Budget& Position Count: Total Program Budget: $88,544.70 Total Program Position Count: 0.5 Total Agency Budget: $4,563,598.86 Total Agency Position Count: 41 EXH I BIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i.Seniors Farmers' Market 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii Office of Community Services $69A04.95 TOTAL: $69,404.95 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is currently working on expanding the agency's fundraising efforts.HCEOC is conducting a trial monthly fundraiser.HCEOC-is also working on increasing their social media presence on Facebook and Instagram .in order to begin the fundraising efforts. Its is exploring new innovative methods to raise funds for the Seniors'Farmers' Market program and the agency's other programs. Throughout the fiscal year, HCEOC continues to search and apply for government and foundation grants'that address the food security needs of the community. In.December 2020,HCEOC was awarded a two-year grant from the State of Hawai`i Office of Community Services to continue the Seniors Farmers'Market Nutritional Program for the county. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of this program is to increase access and consumption of locally grown healthy produce for low-income seniors (65+years old)residing in East Hawai`i(North and South Hilo, Puna and Ka'u). Objective 1: Increase the number of East Hawai`i seniors by 50%participating and redeeming coupons for fresh produce. Outcome/Result: By the end of this program period,the Seniors Farmers'Market increase access and consumption of locally grown fresh produce for seniors residing in East Hawai`i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2Q21-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Seniors Farmers' Market 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they hove participated in your program?Describe,be specific.) Outreach activities provided in East Hawai`i communities 15 Seniors enrolled 600 Coupons redeemed 4,500 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $31,585.97 $5,554.95 $26,031.02 Professional Fees $3,128.63 $3,128.63 Operations $8,324.77 $8,324.77 Supplies $300.33 $300.33 Equipment Other: Coupons for fresh produce $45.205.00 $63,850.00 Other: Other: Other: Other: TOTAL $88,544.70 $69,404.95 $37,784.75 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Seniors Farmers' Market 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): [l Member or members of the Council ri Staff appointed by a member of the Council The Mayor n The Managing Director C The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: X If no conflicts exist, check here. Signature of AuthorU-d Person(specify title) D. e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawaii Seniors Farmers' Market 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to.Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we)understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County.of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Seniors Farmers` Market 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Newell, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a.maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return thesefunds in a timely manner will impact the evaluation of your agency's future funding requestand may result in actions takento recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Uv �r� /14 Signature of Au orized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: East Hawai`i Seniors Farmers' Market 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Outreach activities provided in East Hawaii communities 15 Seniors enrolled 600 Coupons redeemed 4,500 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $26,031.02 Professional Fees $3,128.63 Operations $8 324.77 Supplies $300.33 Equipment Other: Other: Other: Other: Other: TOTAL $37,784.75 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HawaN County [Economic Opportunity/ Council KOkua 0 Puna 114 . .. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: KOKUA 0 PUNA Agency Director: Chad Hasegawa Phone No.: (808)961 — 2681 Contact Person: Greg Ayau Phone No.: (808) 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Email Address: hceocwriter@hceoc.net Fax No.: (808) 961— 2812 Accountant/CPA: Phone No.: (808) 930— 6850 Firm (if applicable): Carbonaro CPAs&Management Company Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $250,000 Geographical Areas To Be Served: (One or more can be checked) Puna ❑ Hamakua ❑ North Kona ❑South Hilo North Kohala South Kona ❑North Hilo ❑South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities 111 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Havvai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: KOKUA 0 PUNA 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 0 0 2.Agency Mission Statement: HCEOC's mission is to reduce, mitigate and alleviate poverty.In 1965, HCEOC was established as a private non-profit organization. It qualifies as a Community Action Agency (CAA) governed by a 12 member tri-partite Board of Directors, equally representing public,private and low-income community members. HCEOC mobilizes public and private resources to assist low-income households,seniors and individuals with disabilities who face multiple barriers due to poverty. Its goal is to enable them to become more self-sufficient and enjoy a higher quality of life through programs and services that reduce,mitigate and alleviate the impacts of poverty in Hawai`i County. 3. Program Description: During the Food Out Food Assistance Program which was funded by the County of Hawaii CARES Act Funds,HCEOC recognized the unique needs of the Puna District. To address the food insecurities of the underserved, low-income community, HCEOC would like to provide a food assistance program to the district.HCEOC will provide food items, such as produce/protein boxes and shelf-stable foods sourced from local Hawaii Island vendors as much as possible. HCEOC will work with community partners will distribute the food items.The goal is to address a need in the Puna District while supporting local businesses. 4.Total Budget&Position Count: Total Program Budget: $250,000 Total Program Position Count: 3 Total Agency Budget: $4,563,598.86 Total Agency Position Count: 41 • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 ' f County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name:KOKUA 0 PUNA 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Nonprofit Grant $250;000 • TOTAL: $250,000 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: HCEOC is currently working on expanding the agency's fundraising efforts.HCEOC is conducting a trial monthly fundraiser.HCEOC is also working on increasing their social media presence on Facebook and Instagram in order to begin the fundraising efforts. It is exploring new innovative methods to raise funds for the Food Service program and the agency's other programs. Throughout the fiscal year,.HCEOC continues to search and apply for government and foundation grants to address the food security needs of the community.The agency is also exploring program • ideas to expand the existing programs to address the need.HCEOC provides a Nutrition Transportation and a Seniors Farmers'Market program to Hawai`i Island. 7.Program Objectives Using County Nonprofit Grant.Program Funds: The goals of this program is to.address the food insecurities of Puna district and increase the access to food. Objective 1: For six months, twice a month,HCEOC will deliver food items, such as protein/ produce boxes and shelf-stable foods to community partners in Puna district to distribute to 250 underserved, low-income households. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of IIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: KOKUA 0 PUNA 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i,e.:Now are youmeasuring what happens for the Participants after theyhave participated in your program?Describe,be specific.) Provide food items(example:produce/protein boxes.shelf-stable foods)two times a month to underserved,low- 250 households income families for six months. Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $8,800 $8,800 Professional Fees Operations Supplies $5;000 $5,000 Equipment Other: Delivery $1,200 $1,200 Other: Food $220.000 $220,000 Other: Administrative $15,000 $15,000 Other: Other: TOTAL $250,000 $250,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: KOKUA 0 PUNA } so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): U Member or members of the Council Staff appointed by a member of the Council 1 The Mayor The Managing Director ri The Director of Finance 1 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: H If no conflicts exist, check here. an i111fPi Signature of Auth sized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name:KOKUA 0 PUNA 11. Certification of Understanding (Page 1 of 2) I (we)have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we)hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will notbe reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of.Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 . { County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: KOKUA 0 PUNA 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recoverthese funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authori ed Person Date i Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: KOKUA 0 PUNA 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide food items(example: produce/protein boxes, shelf-stable foods) 250 households two times a month to underserved, low-income families for six months. TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $8,800 Professional Fees Operations Supplies $5,000 Equipment Other: Delivery $1,200 Other: Food $220,000 Other: Administrative $15,000 Other: Other: TOTAL $250,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Havvaiii County Economic Opportunity Council Mass Transit East Hawaii 115 1 County of Hawai`i Nonprofit Grant Application FY2021-22 • Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawaii Agency Director: Chad Hasegawa Phone No.: (808) 961—2681 Contact Person: Chad Hasegawa Phone No.: (808)961 —2681 Mailing Address: Address: 47 Rainbow Drive Address: City,sr,zip Hilo,HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Email Address: hceocwriter@hceoc.net Fax No.: (808) 961 —2812 Accountant/CPA: Phone No.: (808)930 —6850 Firm (if applicable): Carbonaro CPAs &Management Group Mailing Address: Address: PO Box 4372 city,sr,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE.TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $120,022.17 Geographical Areas To Be Served: (One or more can be checked) ❑� Puna ❑ Hamakua [ North Kona 0 South Hilo ❑ North Kohala ❑South Kona Q North Hilo ❑South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts IMI Aged ❑Victims of Health or Social Crises El Needs of the poor ❑® Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 a + County of Haw-ai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $14,000 2.Agency Mission Statement: HCEOC's mission is to reduce,mitigate and alleviate poverty.The vision of HCEOC is to enable every low-income individual to become self-sufficient.HCOEC is-a private non-profit organization established in 1965.It qualifies as a Community Action Agency(CAA)governed by a 12 member tri-partite Board of Directors,equally representing public,private and low-income community members. According to the Healthcare Association of Hawai'i's Community Health.Needs Assessment published in December 2018,'Hawai`i County has the highest percentage of low-income and ALICE-households in the state at 61%while the state average is 48%.In Hawai'i County,9.4%of seniors(65 years and older)live in poverty.According to United States Department of Agriculture's Economic Research Service,in 2015,5.8%of Hawaii County seniors lived more than 1 mile from a supermarket in urban areas or more than 10 miles from a supermarket in rural areas.For individuals with disabilities,transportation continues to bea critical barrier. 3. Program Description: HCEOC has two County of Hawai`i contracts to provide transportation: 1)Mass Transit and 2)Nitrition Transportation Services.Both contracts do not provide enough funds to cover the cost of operations through the fiscal year.For example,the actual cost per trip is approximately$12 but HCEOC receives$7.25 from its contracts.HCEOC is forced to cover the shortage through other grants.Because of the shortfall,funds that are available through the State of Hawai1's Office of Community Services are diverted to assist the transportation program.The diversion of funds seriously compromises the operation of the agency's other programs. HCEOC's transportation program provides a range of services in East Hawai'i(North and South Hilo,Puna and Keil) from identifying participants in the target population groups to implementing specialized transportation and point-to- point services.Clients are taken to destinations such as medical clinics,shopping areas,government offices and prior to COVID-19 guidelines,county nutritional sites,adult day care centers,and social and recreational activity sites.Trips to and front home are provided at no cost to the qualified population.Some HCEOC vehicles are equipped with wheelchair lifts to safely load and unload passengers with wheelchairs. HCEOC's transportation program ensures that the elderly,individuals with disabilities and low-income residents will not be denied access to essential services or employment because of their ability to drive or find adequate transportation. 4.Total Budget&Position Count: Total Program Budget. $690,396.87 Total Program Position Count: 9 Total Agency Budget: -$4,563,598.86 Total Agency Position Count: 41. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name:Mass Transit East Hawai`i 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai`i Mass Transit Island Wide $592,000.00 Hawaii Island United Way AccessHl Seniors Transportation-Island Wide $9,500.00 TOTAL: $601,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is currently working on expanding the agency's fundraising efforts.HCEOC is conducting a trial monthly fundraiser.HCEOC is also working on increasing their social media presence on Facebook and Instagram in order to begin the fundraising efforts.It is exploring new innovative methods to raise funds for the transportation program and the agency's other programs. Throughout the fiscal year,HCEOC continues to search and apply for government and foundation grants that address the transportation needs of the community.In June 2020,HCEOC was awarded a two-year grant from Hawai`i Island United Way for the transportation program to transport seniors to farmers'markets,grocery stores,medical sites,social, community or cultural activities. HCEOC has partnered with other community human services organizations to provide transportation for their clientele. By partnering with other community agencies,we collectively increase our impact.By working together,HCEOC and the other agencies are able to achieve their goals in assisting members of the community. 7, Program Objectives Using County.Nonprofit Grant Program Funds: The goal of this program is to improve the quality of life for low-income households,seniors and individuals with disabilities in East Hawai`i. Objective 1:Provide transportationto essential services including,but not limited to,medical facilities,shopping areas, recreational activities,financial institutions,government agencies and places of employment for a minimum of 300 seniors residing in East Hawaii. Objective 2:Provide transportation to essential services including,but not limited to,medical facilities,shopping areas, recreational activities,financial institutions,government agencies and places of employment for a minimum of 200 individuals with disabilities residing in East Hawaii. Objective 3:Provide transportation to essential services including,but not limited to,medical facilities,shopping areas, recreational activities,financial institutions,government agencies and places of employment for a minimum of 200 low-income working individuals residing in East Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawai`i 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Senior Passenger Trips for 300-individuals 62,400 units Individuals with Disabilities Trips for 200 individuals 60.000 units Low Income Passenger Trips for 200 individuals 41,000 units Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $540.652.56 $427,550.00 $113,102.56 Professional Fees $28.619.61 $21,700.00 $6919.61 Operations $120.732.03 $141,750.00 Supplies $392.67 $1.000.00 Equipment Other: Other: Other: Other: Other: TOTAL $690,396.87 $592,000.00 ,$120,022.17 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of f Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawai`i 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: N. If no conflicts exist,check here. i • / tz i, (34 Signature of Authorize, Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawai`i 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed_or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County.of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 202 .-2022 Page 6 of 8 • • - County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawai`i 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Itwolei Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit East Hawai`i 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Senior Passenger Trips for 300 individuals 62,400 units Individuals with Disabilities Trips for 200 individuals 60,000 units Low Income Passenger Trips for 200 individuals 41,000 units TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $113,102.56 Professional Fees $6,919.61 Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $120,022.17 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawaii County Economic Opportunity Council Mass Transit West Hawaii 116 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i Agency Director: Chad Hasegawa Phone No.: (808)961 — 2681 Contact Person: Chad Hasegawa Phone No.: (808)961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo.HI 96720 Email Address: hceocwriter@hceoc.net Fax No.: (808)961 — 2812 Accountant/CPA: Phone No.: (808)930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Company Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $120,022.17 Geographical Areas To Be Served: (One or more can be checked) ❑Puna n Hamakua [ North Kona ❑South Hilo Q North Kohala IN South Kona ❑ North Hilo 0 South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $20,750 2.Agency Mission Statement: HCEOC's mission is to reduce, mitigate and alleviate poverty. The vision of HCEOC is to enable every low-income individual.to become self-sufficient. HCEOC is a private non-profit organization established in 1965. It qualifies as a Community Action Agency(CAA) governed by a 12 member tri-partite Board of Directors, equally representing public, private and low-income community members. According to the Healthcare Association of Hawai`i Community Health Needs Assessment published in December 2018,Hawaii County has the highest percentage of low-income and ALICE households in the state at 61%while the state average is 48%. In Hawai`i County, 9.4% of seniors (65 years and older)live in poverty.According to United States Department of Agriculture's Economic Research Service, in.2015, 5.8%of Hawai`i County seniors lived more than 1 mile from a supermarket in urban areas or more than 10 miles from a supermarket in rural areas.For individuals with disabilities, transportation continues to be a critical barrier. 3. Program Description: HCEOC has two County of Hawai°i-contracts to provide transportation: 1)Mass Transit and 2)Nutrition Transportation Services.Both contracts do not provide enough funds to cover the cost of operations through the fiscal year.For example,the actual cost per trip is approximately$12 but HCEOC receives $7.25 from its contracts.HCEOC is forced to cover the shortage through other grants.Due to the shortfall, funds available through the State ofHawai`i's Office of Community Services are diverted to assist the transportation program.The diversion of funds seriously compromises the operation of the agency's other programs. HCEOC's transportation program provides a range of services in West Hawai`i(Hamakua,North and South Kona,North and South Kohala) from identifying participants in the target population groups to implementing specialized transportation and point-to-point services. Clients are taken to destinations such as medical clinics, shopping areas,government offices and prior to COVID-19 guidelines,county nutritional sites, adult care centers, social and recreational activity sites. Trips to and from home are provided at no cost to the qualified population. Some HCEOC vehicles are equipped with wheelchair lifts to safely load and unload passengers with wheelchairs. HCEOC's transportation program ensures that the elderly, individuals with disabilities andlow- income residents will not be denied access to essential services or employment because of their ability to drive or finde adequate transportation. 4.Total Budget&Position Count: Total Program Budget: $690,396.87 Total Program Position Count: 9 Total Agency Budget: $4,563,598.86 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2o21-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i`i 5.Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai`i Mass Transit-Island Wide $592,000 Hawaii Island United Wav AccessHI Seniors Transportation-Island. Wide $9.500 TOTAL: $601,500 Attach additional pages,if needed, 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is currently working on expanding the agency's fundraising efforts. HCEOC is conducting a trial monthly fundraiser. HCEOC is also working on increasing their social media presence on Facebook and Instagram in order to begin the fundraising efforts.It is exploring new innovative methods to raise funds for the transportation program and the agency's other programs. Throughout the fiscal year, HCEOC continuesto search and apply for government and foundation grants that address the transportation needs of the community.In June 2020, HCEOC was awarded a two-year grant from Hawai`i Island United Way for the transportation program to transport seniors to farmers'markets, grocery stores,medical sites, social,community or cultural activities. HCEOC has partnered with other community human services organizations to provide transportation for their clientele. By partnering with other community agencies, we collectively increase our impact.By working together,HCEOC and the other agencies are able to achieve their goals in assisting members of the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the program is to improve the quality of life for low-income households, seniors and individuals with disabilities in West Hawaii. Objective 1: Provide transportation to essential services including, but not limited to,medical facilities, shopping areas,recreational activities, financial institutions, government agencies and places of employment for a minimum of 150 seniors residing in West Hawaii. Objective 2: Provide transportation to essential services including, but not limited to, medical facilities, shopping areas, recreational activities, financial institutions, government agencies and places of employment for a minimum of 200 individuals with disabilities residing in West Hawai'i. Objective 3: Provide transportation to essential services, but not limited to, medical facilities, shopping areas,recreational activities,financial institutions, government agencies and places of employment for a minimum of 100 low-income working individuals residing in West Hawai`i EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i`i 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES. (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Senior Passenger Trips for 150 individuals 31,200 units individuals with Disabilities Trips for 200 individuals 60.000 units Low Income Passenger Trips for 100 individuals 41,000 units Attach additional pages as necessary. • 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $540,652.56 $427,550.00 $113,102.56 Professional Fees. $28,619.61 $21,700.00 $6919:61 Operations $120,732.03 $141,750.00 Supplies $392.67 $1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $690,396.87 $592,000.00 $120,022.17 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director ❑ The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify anyand all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here. /7,04f E}}E Signature of Autho+ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i ii. Certification of Understanding (Page I.of 2) I (we)have read and understood all of the eligibility requirements;grant conditions; award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the.Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract,or program for which funds were used. I (we.) hereby certify that information supplied herein, including all supporting documents, is correct and that l (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand thatinformation supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are ;complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submita year-end report to the County Council within 60 days after.June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i`i. 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai`i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and acceptedby,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. eAi Signature of Auth rized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 . County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: Mass Transit West Hawai`i 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Senior Passenger Trips for 150 individuals 31,200 units Individuals with Disabilities Trips for 200 individuals 60,000 units Low Income Passenger Trips for 100 individuals 41.000 units TABLE:II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages _$113,102.56 Professional Fees $6,919.61 Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $120,022.17 _ Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawaii County [Economic Opportunity Council West Hawaii Nutrition Transportation 117 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Qpportunity Council Program Name: West Hawai`i Nutrition Transportation Agency Director: Chad Hasegawa Phone No.: (808)961 — 2681 Contact Person: Chad Hasegawa Phone No.: (808)961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo,HI 96720 Email Address: hceocwriterZhceoc.net Fax No.: (808)961 —2812 Accountant/CPA: Phone No.: (808)930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Company Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $195,469.59 Geographical Areas To Be Served: (One or more can be checked) ['Puna I Hamakua U North Kona South Hilo U North Kohala [South Kona ❑ North Hilo X South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ['Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises Q Needs of the poor ❑Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i. Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutritional Transportation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 1 FY 20-21 $10,500 2.Agency Mission Statement: HCEOC's mission is to reduce,mitigate and alleviate poverty.HCEOC is a private nonprofit organization established in 1965. It qualifies as a Community Action Agency(CAA) governed by a 12 member tri-partite Board of Directors,equally representing public, private and low-income community members. HCEOC mobilizes public and private resources to assist low-income households, seniors and individuals with disabilities who face multiple barriers due to poverty. Its goal is to enable them to become more self-sufficient and enjoy a higher quality of life through programs and services that reduce,mitigate and alleviate the impacts of poverty in Hawai`i County. 3. Program Description: No hungry seniors on Hawai`i Island are the fundamental purpose for HCEOC's Nutrition Transportation.Program.An estimated 22%of Hawaii County's population is 65 years or older.A majority of seniors are living on a fixed income while managing the increased cost of living, health care expenses and COVID-19 related issues. The county has an estimated 12% of seniors who are living below the poverty level. AccessHl Transportation Program transports low-income seniors (65+years)with limited or no transportation access to congregated meal sites (has been canceled due to COVID-19), grocery stores and farmers'markets. Clients are picked up at home,taken to county nutrition sites, grocery stores and/or farmers'markets then return home at no cost. While HCEOC has a County of Hawai`i contract for nutrition transportation, the funds are not enough to cover the cost of operations throughout the fiscal year.For example,the actual cost per trip is approximately $12 but HCEOC receives only$7.25 from its contracts and is forced to cover the overage through other funding sources. 4.Total Budget& Position Count: Total Program.Budget: $332,284.30 Total Program Position Count: 4.5 Total Agency Budget: $4,563,598.86 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutrition Transportation 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai`i Office of Aging $136,843.00 Hawai`i Island United Way AccessHI Seniors Transportation-Island Wide $9.500,00 TOTAL: $146,343.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is currently working on expanding the agency's fundraising efforts.HCEOC is conducting a trial monthly fundraiser.HCEOC is also working on increasing their social media presence on Facebook and Instagram in order to begin the fundraising efforts. It is exploring new innovative methods to raise funds for the transportation programs and the agency's other programs. Throughout the fiscal year,HCEOC continues to search and apply for government and foundation grants that address the transportation needs of the community. In June 2020, HCEOC was awarded a two-year grant from the Hawaii Island United Way for the transportation program to transport seniors to farmers'markets, grocery stores, medical sites, social, community or cultural activities. HCEOC has partnered with other community human services organizations to provide transportation for their clientele. By working together, HCEOC and the other agencies are able to achieve their goals in assisting members of the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the program is to improve the quality of life for seniors and individuals with disabilities in West Hawai`i (Harnakua,North and South Kohala,North and South Kona)to have transportation to access nutrition programs including Seniors Farmers'Market. Objective 1: Provide transportation to 150 seniors (65+years old) and individuals with disabilities residing in West Hawai`i to nutrition sites and Seniors Farmers'Market sites. To accomplish this objective, HCEOC will dedicate three drivers and three vans to serve West Hawai`i. HCEOC will collaborate with County Nutrition sites and Seniors Farmers'Market sites in West Hawai`i communities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutrition Transportation 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the,Participants after they have participated in your program?Describe,be specific.) Enroll low-income seniors 65 years or older,individuals with disabilities 150 individuals Provide transportation to nutrition sites,senior farmers'markets and grocery stores(unit is one way transport) 1.000 units Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req • Salary and Wages $220,732.47 $85.239.31 $135.493.16 Professional Fees $25.524.16 $9,253.13 $16,271.03 Operations $85,556.71 $41,851.31 $43,705.40 Supplies $470.96 $500.00 Equipment • Other: Other: Other: Other: Other: TOTAL $332,284.30 $136.843.75 $195,469.59 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutrition Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply); Member or members of the Council n Staff appointed by a member of the Council The Mayor I I The Managing Director I I The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here. C\0404/1 Signature of •uth i'rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutrition Transportation 1�. Certification of Understanding (Page 1 of 2) I (we)have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we)understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding,of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 { Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutrition Transportation. 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. dA,A, Signature of thorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 4 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Nutrition Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Enroll low-income seniors (65+years old), individuals with disabilities 150 individuals Provide transportation to nutrition sites, seniors farmers'markets and 1.000 units grocery stores(unit is one way transport) TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $135,493.16 Professional Fees $16,271.03 Operations $43,705.40 Supplies. Equipment Other: Other: Other: Other: Other: TOTAL $195,469.59 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawaii County [Economic Opportunity Council West Flawai'i Seniors Farmers' Market 118 • T County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Seniors Farmers' Market Agency Director: Chad Hasegawa Phone No.: (808)961 — 2681 Contact Person: Chad Hasegawa Phone No.: (808)961 — 2681. Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo.HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo;HI 96720 Email Address: hceocwriter@hceoc.net Fax No.: (808)961 — 2812 Accountant/CPA: Phone No.: (80&1930—6850 Firm (if applicable): Carbonaro CPAs &Management Company Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO.KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $37784.75 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna (J Hamakua 0 North Kona South Hilo Q.North Kohala ❑® South Kona ❑North Hilo El South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts n Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 } C County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Seniors Farmers' Market 1. Prior Year Award of County Nonprofit Grant Program Funds: • FY 18-19 FY 19-20 FY 20 21 $16,5000 2.Agency Mission Statement: HCEOC's.mission is to reduce, mitigate and alleviate poverty. In 1965, HCEOC was established as a • private non-profit organization. It qualifies as a Community Action Agency(CAA) governed by a 12 member tri-partite Board of Directors, equally representing public, private and low-income community members. HCEOC mobilizes public and private resources to assist low-income households, seniors and individuals with disabilities who face multiple barriers due to poverty. Its goal is to enable them to become more self-sufficient and enjoy a higher quality of life through programs and services that reduce, mitigate and alleviate the impacts of poverty in Hawai`i County. 3. Program Description: Healthy food means healthy seniors. Seniors Farmers'Market provides low-income seniors (65 years and older)with a coupon book of 10 five dollar coupons to purchase produce at farmers'markets. With this program,HCEOC will provide coupons and transportation to the Food Basket Mobile Market and Da Box distribution sits for qualified seniors. Currently,the Seniors Farmers' Market funding provides coupons from April through September.Through this project, staff will conduct outreach and enrollment events. Staff will also work with farmers' markets,Food Basket and Da Box to ensure seniors have access to fresh produce. The target population to be served is a minimum of 600 low-income seniors (65 years and older) individuals residing in West Hawai`i including: Hamakua,North and South Kohala, North and South Kona. Currently,the State of Hawai`i Office of Community Services provides$69,404.95 to administer the program on Hawai`i Island. A majority of the funds(93%) is allocated directly to coupons. The remaining funds is allocated to administrative cost This proposal will provide additional funds to increase distribution of applications to seniors across the island for a full year. 4.Total Budget&Position Count: Total Program Budget: $88,544.70 Total Program Position Count: 0.5 Total Agency Budget: $4,563,598.86 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 • Agency Name: Hawaii County Economic Opportunity Council • Program Name: West Hawai`i Seniors Farmers' Market 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate • State of Hawaii Office of Community Services $69,404.95 TOTAL: $69,404.95 • Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: • • HCEOC is currently working on expanding the agency's fundraising efforts. HCEOC is conducting a trial monthly fundraiser. HCEOC is also working on increasing their social media presence on Facebook and Instagram in order to begin the fundraising efforts. It is exploring new innovative methods to raise funds for the Seniors Farmers'Market program and the agency's other programs. Throughout the fiscal year, HCEOC continues to search and apply for government and foundation grants that address the food security needs of the community. In December 2020, HCEOC was awarded a two-year grant from the State of Hawai`i Office of Community Services to continue the Seniors Farmers'Market Nutritional Program for the county. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of this program is to increase access and consumption of locally grown healthy produce for low-income seniors (65+years old) residing in West Hawai`i (Hamakua,North and South Kohala, North and South Kona). Objective 1: Increase the number of West Hawai`i seniors by 50% participating and redeeming coupons for fresh produce. Outcome/Result:By the end of this program period,the Seniors Farmers' Market increase access and consumption of healthy locally grown fresh produce for seniors residing in West Hawai`i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawaii Seniors Farmers' Market 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeosuring what happens for the Participants after they have participated in your program?Describe,be specific.) Outreach activities provided in West Hawaii communities 10 outreach events Seniors enrolled 500 Coupons issued 5000 Coupon redeemed 4475 Attach additional pages as necessary, 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $31,585.97 $5,554.95 $26,031.02 Professional Fees $3;128.63 $3,128.63 Operations _ $8.324.77 $8,324.77 Supplies $300.33 $300.33 Equipment Other: Coupons for fresh produce $45.205.00 $63,850 Other: Other: Other: Other: TOTAL $88,544.70 $69,404.95 $37,784.75 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 { County of Hawaii.Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Seniors Farmers' Market 10. ORGANIZATION. CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council I I The Mayor The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: �M If no conflicts exist, check here. Ori Vit (404111t1 Signature of A thorized Person (specify title) Da e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i. Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i.Seniors Farmers' Market zs. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai`i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,complete,and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 I ' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Seniors Farmers' Market 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 9 1 P2( Signature f Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2Q21-22 Agency Name: Hawaii County Economic Opportunity Council Program Name: West Hawai`i Seniors Farmers' Market 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Outreach activities provided in West Hawaii communities 10 outreach events Seniors enrolled 500 Coupons issued 5000 Coupons Redeemed 4475 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $26,031.02 _ Professional Fees $3,128.63 Operations $8,324.77 Supplies $300.33 Equipment Other: Other: Other: Other: Other: TOTAL $37,784.75 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawai'i Institute of Pacific Agriculture (HIP Ag) 'Aina Lessons: Farm to Fork in Hawaii 120 1 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:HARAifirglittfigf Pacific Agriculture(HIP Ag) Program Name: `Aina Lessons:Farm to Fork in Hawaii Agency Director: Dash Kuhr Phone No.:(808 ) 896-6084 Contact Person: Erika Kuhr Phone No.:( 808 ) 896=5551 Mailing Address: Address:' PO Box 497 Address: City,ST,Zip Kapaau,HI 96755 Facility Address: Address: 52-4700 Akoni Pule Hwy Address: City,ST,Zip Kapaau, HI 96755 Email Address: ainafest@hipagriculture.org Fax No.: ( ) — Accountant/CPA: Patty Schumacher Phone No.:(928)) 772- — 5878 Firm (if applicable): Schumacher Tax and Accounting Mailing Address: Address: PO Box 395 City,ST,Zip Dewey,AZ 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $16,100 Geographical Areas To Be Served: (One or more can be checked) Puna Q Hamakua © North Kona Q South Hilo ® North Kohala ®South Kona North Hilo 0 South Kohala Q Ka`u • Services or Activities To Be Provided: (One or more can be checked) ® Educational concerns ®Youth ❑Victims of Crimes E Culture and the arts 7 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hangtii-dilttifintieurtf of Pacific Agriculture(HIP Ag) • • Program Name: `Aina Lessons: Farm to Fork in Hawai'i 1. Prior Year Award.of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0 $0 $5,500 • 2.Agency Mission Statement: To practice and teach regenerative agricultural education programs Vision: Heal and inspire Hawaii through resilient agriculture education: Values and Gliding principles 1.Practice regenerative ag that produces food and medicine 2.Provide experiential,place-based,career connected education. 3.Be food movement leaders. 4.Promote the Rights of the people to access healthy land and food 5.Practicing methods of farming that increases the health of the land and • environment. 6.Teach agriculture connected nutrition and wellness 3. Program Description: Due to-the continuing threat of the COVID-19 pandemic and current restrictions,HIP Ag plans to continue this new format for the'Aina Festival turned into high quality educational videos that are entirely virtual.The 12th Annual'Aina Fest,"Aina Lessons: Farm to Fork Part II"for 2021 will continue the educational video series:10 short videos,around 5 minutes in length each.The 2020 11th Annual Aina Fest turned into a series of agriculturally focused educational video and audio content highlighting the following subjects: Growing Local Food(featuring seed-saving,compost building,garden bed preparation,tropical plant species,homestead design with themes of permaculture,agroforestry,and tropical gardening 101). Cooking Local Starches(focused on kalo,plantains,'ulu,and cassava featuring replicable recipes). With positive feedback from Hawaii residents and students,we would like to do another series. This year we will focus on 10 videos that are 5 minutes long to better suit the viewer demands.Five videos will be focused specifically on crop production that is popular and growing in demand here on Hawai`i island.Another 5 videos will be produced on how to cook these crops for home consumption.Specific crops will be identified as we grow our viewership with the current'Aina Festival video series.HIP Ag is committed to supporting local food production and consumption by empowering farmers and Hawaii island residents through education by continuing to offer Aina Fest virtually.The new objectives of this project include promoting local food and local food production to increase local food consumption through educational video content.While also providing network and partnership opportunities for local farmers,agricultural businesses,and non-profit organizations to increase local food production and education.To meet our objectives throughout the project period we will strive to plan,prioritize,and execute the Teveentgwhich includes video productiongand educational content,booking educators,in addition to securing sponsors and viewers 4. iota! uclget&Position Count: Total Program Budget: $28,100 Total Program Position Count: 2 Total Agency Budget: 601,905 Total Agency Position Count: 7 • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 ' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hall/ aCiIPAINt oqPacific Agriculture(HIP Ag) `Aina Lessons:Farm to Fork in Hawaii Program Name: 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Department of Agriculture $5,000 Business Sponsorship(Hawaii Center for food safety,Ulupono,Natural Investments,Kona Brewery,etc.) $7,000 TOTAL: $12,000 Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: In the previous year,we received$3,750.00 for sponsorship from businesses and$10,000 from HIDOA.We feel we will be able to attain equal or more sponsorship funds as last year,especially since we have the'Aina Lessons Part 1 series of 16 videos to show for it and the second year will gain more popularity and views.We will be able to use the current videos that are out to gain sponsorship for the upcoming season. • 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide agricultural education via video and audio content to offer Hawaii State residents a living online resource to support and increase local food information,production,and consumption. 2. Feature local educators from non-profit organizations,businesses,and the community at large to support and increase local food production and consumption. 3. Provide network and partnership opportunities for local farmers,agriculture businesses,and non-profit organizations to support and increase local food production. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i, }NI{onprofit Grant Application . FY2021-22 Agency Name: Ha ,�;�l IMe off Pacific Agriculture(HIP Ag) `Aina Lessons:Farm to Fork in Hawaii Program Name: • 8.TABLE I: • What are the measurable performance outcomes,that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) - 10,000 of views of the video series Social media,Youtube,Vimeo analytics • 10 educational videos produced and released to the public Vimeo,YouTube,Social Media,Website, and shared directly with teachers Attach additional pages as necessary. 9.TABLE II: • PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 • Actual* Total Budget Grant Req Salary and Wages 7,560 7,560 0 Professional Fees 15,658 18,600 14,250 Operations 400 500 500 Supplies 950 1,350 1,350 Equipment 419 - 0 Other: Other: Other: Other: Other: TOTAL 24,987 28,010 16,100 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 7- County of Hawai`i Nonprofit Grant Application . FY2021-22 Agency Name: HawfgAiTtaNtgf Pacific Agriculture(HIP Ag) `Ai.na Lessons:Farm to Fork in Hawai i Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, .or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,.with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): fl Member or members of the Council • ® Staff appointed by a member of the Council O The Mayor in The Managing Director The Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 11 If no conflicts exist, check here. • Vice President/Executive Director 01/29/2021 c :_1(14,Az A:41A 1 Signature of Authorized Person (specify title) Date -EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i }Nonprofit Grant Application FY2021-22 awa�I Agency Name: Hawns lTilt_of Pacific Agriculture(HIP Ag) Program Name: `Aina Lessons:Farm to Fork in Hawaii 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. • I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. • I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai`i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A . NONPROFIT GRANT APPLICATION " FY 2021-2022 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Hawiitute of .Program Name: Aura Lessons:Farm to Fork in Hawaii • 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted-to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to•return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01/29/2021 Signature of Authorized Person Date Vice President/Executive Director • Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Haw illagtitute of `Aina Lessons:Farm to Fork in Hawaii Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request- Award Salary and Wages Professional Fees Operations Supplies • Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B • NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawai'i Institutes of Pacific Agriculture (HIP Ag) Keiki to Kupuna Care Bags 121 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Figawailhhtimitua of Pacific Agriculture (HIP Ag) Program Name: Keiki to Kupuna Care Bags Agency Director: Dash Kuhr Phone No.:(808 ) 896 —6084 Contact Person: Erika Kuhr Phone No.:(808 )896 —5551 Mailing Address: Address: PO Box 497 Address: City,ST,Zip Kapaau,HI 96755 Facility Address: Address: 52-4700 Akoni Pule Hwy Address: City,ST,Zip Kapaau,HI 96755 • Email Address: erika@hipagriculture.org Fax No.: - ( ) — Accountant/CPA: Patty Schumacher Phone No.:( 928) 772 —5878 Firm (if applicable): Schumacher Tax and Accounting Mailing Address: Address: PO Box 395 City,ST,Zip Dewey,AZ 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO. PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑ Hamakua ❑ North Kona ❑South Hilo ® North Kohala ❑South Kona • ❑North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑x Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises F Needs of the poor ❑ Physical/Emotional Disabilities In Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 } County of Hawai`i Nonprofit Grant Application , FY2021-22 Agency Name: Hagau ins titute of Program Name: Keiki to Kupuna Care Bags 1. Prior Year Award of County Nonprofit Grant Program Funds: • • FY 18-19 FY 19-20 FY 20-21 0 0 $9,250 2.Agency Mission Statement: Mission:To practice and teach regenerative agricultural education programs Vision:Heal and inspire Hawaii through resilient agriculture education. Values and Guiding principles 1. Practice regenerative ag that produces food and medicine 2. Provide experiential,place-based,career connected education. 3. Be food movement leaders. 4. Promote the Rights of the people to access healthy land and food 5. Practicing methods of farming that increases the health of the land and environment. 6. Teach agriculture connected nutrition and wellness 3. Program Description: In August of 2019,HIP Ag launched a food aggregation hub called the Kohala Food Hub(KFH)which serves as a distributor for more than 30 local farmers and value-added producers and as a market to the local community for fresh produce.At the onset of COVID-19 in March 202Q,KFH began distributing a weekly"Kupuna Care Bag" to the North Kohala community which gives 4-10 lbs of locally grown produce to 40 local elders on a fixed or low income.That provides about$3,500 of revenue to our local Kohala farmers a month through this program alone.HIP Ag now seeks to fund a new"Keiki to Kupuna Bag"program to target another 50 families who have an elder or other family member who is unemployed or on a fixed income and is providing childcare services.As our community returns to work,childcare has become a hinge point on whether our community can afford to go to work.The choice to return to work or stay home to provide childcare is a critical one for residents of North Kohala with children in the Pre-K and elementary ages.Kamehameha Preschool is the only preschool active in North Kohala,leaving residents with little to no options for childcare except for elders in the family,or family members who are unemployed.While the services of elder family members or other family members as child care providers is traditionally aligned without a village system,it does not address the economic disparities these families face on fixed incomes.Recipients will receive weekly bags featuring local fruits and vegetables and healthful snacks for the family.Besides closing food security gaps for families in the North Kohala region,this project simultaneously provides another market of demand for our local producers. - The project staff will also provide an educational component for the participants/recipients of this project.These educational components will enhance the relationship between Kohala families and their local food systems,raising awareness of the availability and reliability of locally grown foods.Educational emphasis on regionally local food(food coming directly from the district or island vs,the state)also connects the participants to their land base,Kohala and Hawaii Island. 4.Total Budget& Position Count: Total Program Budget: $60,721 Total Program Position Count: 3 Total Agency Budget: $601,905 Total Agency Position Count: 7 EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 ' Agency Name: Hawaii Institute of HIP Ag Program Name: Keiki to Kupuna Care Bags 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate KFH Kupuna Monetary Donations $9,850 Kohala Food Hub $5,000 TOTAL: $14,850 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Donor Campaign-In 2020,KFH sought to strengthen and diversify its funding sources beyond weekly online marketplace sales by giving its shoppers opportunities to sponsor its Kupuna Care Bag and Farm-to-School programs.It raised nearly$9,850 from 40 small-dollar donors,showing the power of its grassroots supporter network. Drawing upon its past fundraising success,KFH will encourage shoppers to donate to its"Keiki to Kupuna"program with an engagement campaign promoted through local advertising,email,and social media.KFH shoppers will be asked to adopt a family and get periodic updates about the food and other benefits their support provides to that family.This will better demonstrate to donors the impact of their support while personalizing the experience and fostering empathy within the community. Increased Markets-In addition KFH itself is expanding its wholesale markets for our local producers.The expansion of markets , will also result in increased revenue for the Kohala Food Hub and our programs like the Care bags. • 7. Program Objectives Using County Nonprofit Grant Program Funds: • 1.Increase food security for 90 families in Kohala ranging in ages from keiki to Kupuna through these weekly care packages. Packages are provided to teach family weekly either through a delivery service,or via pick up at our KFH location on Hoea Road in Hawi. 2.Increase food awareness for local products,and place based food systems The Keiki to Kupuna bags will also include an educational handout with recipe and product/produce information.Additionally, HIP Ag's education team will host a monthly virtual activity for recipients focused on products in the box. 3.Promote and improve the agriculture industry in Kohala through the purchase and engagement of local farmers and producers by$31,500 in FY 2021-2022. The produce and products purchased for these care bags will come from the over 20 local Kohala farmers and value-added producers that already work with KFH. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Institute of Ag Program Name: Keiki to Kupuna Care Bags 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 23,400+-Lbs of food provided to elders and families in need in Kohala - 51bs avg/bag/week x 90 families x 52 wks #of family/elders receiving the bags 90+families serviced through the progam Sales from local producers for these care bags. $31,250+paid directly to Kohala farmers #of participants in monthly educational gathering Avg 15 families per month participating in monthly educational sessions Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $8,297 $19,637 $14,637 Professional Fees $2,508 $2,508 Operations $2,130 $3,000 Supplies $1,910 $3,820 Equipment Other: Travel(Delivery service for care bags) $570 $1,139 Other: Printing $938 $1,875 Other: Local Kohala Produce $15,625 $31,250 $31,250 Other: Other: . TOTAL $31,976 $60,721 $45,887 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hav ,IlAstitute of Program Name: Keiki to Kupuna Care Bags 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose anyconflicts orpotential conflicts of interest that anyboard member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 Member or members of the Council •. ® Staff appointed by a member of the Council ® The Mayor in The Managing Director The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation - Counsel Conflict of Interest is defined,as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: rIf no conflicts exist, check here. Vice President/Executive Director 01/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii AInstitute of Program Name: Keiki to Kupuna Care Bags 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the-Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we)-understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: H �gnstitute of. IP Program Name: Keiki to Kupuna Care Bags is. Certification of Understanding (Page 2 of 2) - If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for,further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • 01/29/2021 Signature of Authorized Person Date Vice President/executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Institute of HIP Ag Program Name: Keiki to Kupuna Care Bags 12. COUNCIL AWARD WORKSHEET TABLE I: • PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations • Supplies Equipment Other: Other: i Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hawaii Institute of Pacific Agriculture (HIP Ag) Kohala ILalawai: Growing Kohala Farmers, A Farm to School Project 122 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: of Pacific Agriculture (HIP Ag) Program Name: Kohala Lalawai:Growing Kohala Farmers,A Farm to School Project Agency Director: Dash Kuhr Phone No.:(808) 896 —6084 n: Phone No.:(808 )896 —5551 Contact Perso Erika Kuhr Mailing Address: Address: PO Box 497 Address: City,ST,Zip Kapaau,HI 96755 • Facility Address: Address: 52-4700 Akoni Pule Hwy Address: City,ST,Zip Kapaau,HI 96755 Email Address: erika@hipagriculture.org Fax No.: ( ) Accountant/CPA: Patty Schumacher Phone No.:( 928) 772 —5878 Firm (if applicable): Schumacher Tax and Accounting Mailing Address: Address: PO Box 395 City,ST,Zip Dewey,AZ 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES ... ........................ Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To.Be Served: (One or more can be checked) ❑ Puna ❑Hamakua ❑ North Kona ❑South Hilo ®North Kohala ❑South Kona ❑North Hilo ❑South Kohala ❑ Ka u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises • D Needs of the poor ❑ Physical/Emotional Disabilities • ® Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HavislibfAlitute of Program Name: Kohala Lalawai: Growing Kohala Farmers, A Farm to School Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 - FY 19-20 FY 20-21 7,125 11,750 8,000 2.Agency Mission Statement: Mission:To practice and teach regenerative agricultural education programs Vision:Heal and inspire Hawaii through resilient agriculture education. Values and Guiding principles 1. Practice regenerative ag that produces food and medicine - 2. Provide experiential,place-based,career connected education. 3. Be food movement leaders. 4. Promote the Rights of the people to access healthy land and food 5. Practicing methods of farming that increases the health of the land and environment. 6: Teach agriculture connected nutrition and wellness 3. Program Description: Established in 2008,HIP Ag provides programs rograms primarily in Kohala on Hawaii Island.After over 10 years of successful partnerships with Career Hih School Natural Resource Trade the HIDOE Kohala Complex schools,HIP Ag now seeks to partner with the Kohalag Education(CTE)program to grow agricultural career pathways for Kohala High School students,while continuing to expand commercial market opportunity for Kohala producers. Early Hawaiian language newspaper articles referred to the developing youth farmers of Kohala in the late 1800s as"ko•Kohala keiki lalawai,"the prosperous youth of Kohala.Young men were trained in farming peanuts,sugar cane,pigs,and other domestic crops and animals in the Honomaka`u area where the current High School is located.This phrase has become the inspirational motto this year for our Kohala High School Farm students.HIP Ag will partner with the developing CTE Natural Resource pathway at Kohala High School to continue this model of raising young,prosperous farmers of Kohala through our Kohala Lalawai:Growing Kohala Farmers Project. Ten students will be selected for a"Lalawai Apprenticeship"and trained in developing a plot of their crop of choice and developing their business plan around their crop.Lessons will be taught by the HIP Ag education team through partnership with the Natural Resource instructor at Kohala High School.HIP Ag's education team will also assist in facilitation of Natural Resource courses and management of KHS farm.Additionally,the apprentices will receive field experience and additional support and training during the Fall,Spring,and Summer breaks at HIP Ag Farm.On the farm,they will work alongside farmers,learning more detail about specialty crops,best practices for harvest and production,and market development through value-added processes. In order to ensure that these young founders can indeed be Lalawai(prosperous),the Kohala Food Hub will work with these young Lalawai apprentices to get their products to the regional and state markets,providing viable economic opportunities for these young farmers to continue with their career pathway in agriculture. • 4.Total Budget&Position Count: Total Program Budget: $125,385 Total Program Position Count: 5 Total Agency Budget: $601,905 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hniktitute of Program Name: Kohala Lalawai: Growing Kohala Farmers, A Farm to School Project 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate • HIP Agriculture $25,518 Hawaii Community Foundation-Career connected learning $35,000 TOTAL:, 60,518 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since 2014,HIP Ag has served as a trusted partner of HIDOE and supported the pilot and scale of the first Farm to School initiative in the State of Hawaii at the Kohala Complex public schools.In this time,HIP Ag has secured over $500,000 in funding from public and private sources to build its organizational capacity to become a leader in Hawaii's farm-to-school movement.HIP Ag will leverage existing partnerships and secure incoming funding to continue this important work In addition,F2S and youth education programs are cornerstones of HIP Ag's work,and the directors actively fundraise for these activities by pursuing foundation grants,individual donations,and generate revenue through small farm-to- table dinners and farm tours. The F2S initiative will continue to be integral to HIP Ag's programs and mission.The applicant's partners,such as • Kohala Complex DOE,TKC,HIDOA,and HPHI,are invested in these efforts and will collaborate together to identify and pursue funding to sustain F2S efforts. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1:Develop a career pathway for Kohala High School for X KHS students in agriculture related industries(farming to value-added-production). See attached Lalawai Apprenticeship Timeline FY 2021-22 for activities that support this objective: Objective 2:Provide resources to allow apprentices to continue their career pathway development after the apprenticeship ' through Kohala Food Hub(KFH)markets,and partnerships with landowners and existing farms in Kohala. KFH will work with the Lalawai apprentices as producers,assisting them with getting crops to markets.The project staff will also coordinate plot spaces for crop development with HIP Ag Farms and other existing farmers or land owners of Ag Land in Kohala. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hijvetitute of Program Name: Kohala Lalawai: Growing Kohala Farmers,A Farm to School Project 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) - 90%successful completion of the Lalawai Apprenticeship Project Pre and post surveys 700+contact hours of HIP Ag F2S program staff and the Kohala High School CTE Track hours with students and mentorship students and Lalawai apprentices 70%continuation commitment of farm career/small ag business development with Lalawai Post program follow up outreach and apprentices after the program's end Kohala Food Hub team will continue to support young farmers. Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $25,830 $75,285' $39,500 Professional Fees • Operations $1,932 • Supplies • $3,262 $31,100 Equipment - $4,000 $1,000 Other: Travel(use of HIP bus for transporting Lalawai students) $1,650 . $2,000 Other: Apprentice Stipends $6,000 10,000 $10,000 Other: Equipment maintenance $1,985 $3,000 Other: Infrastructure at KHS farm $2,500. Other: TOTAL $43,155 $125,385 $46,500 *If applicable • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HaviaiNktgute of Program Name: Kohala Lalawai: Growing Kohala Farmers,A Farm to School Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): Q Member or members of the Council ® Staff appointed by a member of the Council • The Mayor In The Managing Director ® The Director of Finance Q The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: If no conflicts exist,check here. Zagg:Aa /, _ Vice President/Executive Director 01/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY.2021-22 Agency Name: l ,aistitute of, Program Name: Kohala Lalawai: Growing Kohala Farmers, A Farm to School Project 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, • measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION 'FY 2021-2022 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HfflpiI stitute of Program Name: Kohala Lalawai: Growing Kohala Farmers, A Farm to School Project 11. Certification of Understanding (Page 2 of 2) If awarded a rant from the Countyof Hawaii, I (we) understand that a current Certificate of Liability g ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about • May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. _ /� n�/ ��`� I/„ _ 01/29/2021 Signature( ofofAuthorizedpu7Person�` onDate Vice President/executive Director • Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HawAidnAttute of Program Name: Kohala Lalawai: Growing Kohala Farmers,A Farm to School Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award - Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Lalawai Apprenticeship Timeline FY 2021-22 Jul-Sept: 4. Recruit students from the KHS Natural Resource CTE track. 5. Orient students to the apprenticeship program. 6. Co-host lessons about agriculture production in Natural Resource courses at KHS. Oct-Dec: 4. Fall Break- 1 week focused on plot and crop production. Students will be given a crop or production area at HIP Ag farm and KHS Farm for their apprenticeship production development focus. 5. Students maintain plots during Qtr 2 of the school year. 6. Co-host lessons about agriculture production in Natural Resource'courses at KHS. Jan-Mar: 5. Students maintain plots during Qtr 3 of the school year. 6. Co-host lessons about agriculture production in Natural Resource courses at KHS. 7. Spring Break- week focused on plot and crop production on student's plots at HIP Ag Farm and KHS Farmmfor their crop production. Begin to get crops to markets(for crops in season). 8. Monthly Farm Market- Students get their produce and products to the community through a monthly market facilitated in partnership with the CTE Pathways at Kohala High School. Apr-Jun: 5. Students maintain plots during Qtr 4 of the school year. 6. Co-host lessons about agriculture production in Natural Resource courses at KHS. 7. Monthly Farm Market- Students get their produce and products to the community through a monthly market facilitated in partnership with the CTE Pathways at Kohala High School. 8. Summer Break- 4 weeks in June focused on plot and crop production on student's plots at HIP Ag Farm and KHS Farm for their crop production. Focus is on getting crops to market and establishing students to continue their agricultural production after the apprenticeship. Hawai'i Island Home for Recovery, Inc. HIHR Consolidated HIHR Permanent Supportive Housing Programs 124 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:Consolidated HIHR Permanent Supportive Housing Programs Agency Director: Rita Sandi Palma Phone No.:(808 )640 —9442 Contact Person: Rita Sandi Palma Phone No.:(808)934 —7852 Mailing Address: Address: Address: 440 KaDiolani St. City,ST,zip Hilo, HI. 96720-3937 Facility Address: Address: Address: Same City,ST,Zip Email Address: admin@ hihrecovery.org Fax No.: (808 ) 935 —7894 Accountant/CPA: Alex J. Smith Phone No.:(808) 257 —6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. City,ST,zip Honolulu, HI. 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua 0 North Kona Q South Hilo El North Kohala 0 South Kona ❑■ North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑Youth l Victims of Crimes 0 Culture and the arts ❑■ Aged Q Victims of Health or Social Crises Needs of the poor 0 Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: Consolidated HIHR Permanent Supportive Housing Programs 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 HIHR_PSH1+2+3_$20,213.00 HIHR_PSH1+2+3_$24,121.00 $12,625.00 2.Agency Mission Statement: Prior Year Award of County Nonprofit Grant Program Funds: Consolidated HIHR Permanent Supportive Housing Accumulative Programs Budgets HIHR_FY18-19_PSH1$7,613+PSH2 $6,300+PSH3 $6,300_Total Budgets =$20,213.00 HIHR_FY19-20_PSH1$9,144+PSH2$7,108+PSH3$7,869_Total Budgets =$24,121.00 HIHR Mission is to Serve the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals.The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing, Supportive Permanent Housing and long-term Permanent Housing, improving their life's and general skills,increasing personal income, enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models, as well as Coordinated Data Entry System utilizing VI-SPDATand the Housing First Model Approached. 3. Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Shelter Housing Services since 2006,and Permanent Supportive Housing Services since 2011,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals. Additionally, since 2008 also providing Kitchen and Pantry Food Programs. HIHR utilizes quick books software for financial tracking, which is subcontracted, to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns.HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers,including primarily mental illnesses,substance abuse disorders, dual diagnosis, physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals,asses and creates Individualized Service Plans(ISP)including case management,job training,job placement, substance abuse/mental health treatment,healthcare, living skills,financial training, education, housing resources, entitlements,parenting, domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment, services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide, State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island,a caring living environment that helps restores some individuals to a sounder more balance mind, body and spirit,to live independently. 4.Total Budget&Position Count: Total Program Budget: 397,088.00 Total Program Position Count: 5 Total Agency Budget: 1,760,165.00 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: Consolidated HIHR Permanent Supportive Housing Programs 5.Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate HUD-CoC Grant 314,875.00 HIHR-Program Fees 38,613.00 Hawaii Island United Way 3,100.00 Other Funds 1,500.00 County of Hawaii Non-Profit Grants 39,000.00 TOTAL: 397,088.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County, Institutional,public and or Private Entities. HIHR active searching history dearly shows the development and expansion of our agency programs like Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care COC,administrated by HPO of DHS of the State of Hawaii. HUD-COC funding was afforded for the period Nov 2011-Oct 2015,and lately additional funding for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement. More Importantly as of July 27,2018 Hawaii Island Home for Recovery,Inc.(HIHR)was Designated Approved as a Direct Recipient by HUD_COC,ending many years of contracting as Sub-recipients under HPO of DHS of the State of Hawaii. HIHR annual budget FY2007was just over 150K currently FY2020 was over 1.7M 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description, promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind, body and spirit. As participants are assessed,the Case Manager coordinates HIHR resources and community-based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager promotes the participation in a variety of programs that improves housing stability. HIHR Case Manager/Care Coordinator maintains bi-weekly meetings to process and follow-up activities, also conduct team meetings with providers including probation officers, mental health,substance abuse and medical case managers as part of the support system to follow-up with the goals and objectives of the Individualized Service Plan(ISP) enhancing their well-being. Most chronically homeless population deals with dual diagnosis (substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment, HIHR makes referrals to job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income and stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: Consolidated HIHR Permanent Supportive Housing Programs • 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Case Managing,Comprehensive Assessments,and Individual Service Plan(ISP). 100% Health/Mental Health/substance Abuse Treatment Services. 100% Life Skills Training at HIHR Programs and as well with other Partners Providers in the Community. 90% Maintain Housing and at the exit of HIHR Program to obtain and Maintain Permanent Housing. 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES Pf 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 149,132.00 178,064.00 $25,000.00 Professional Fees 18,644.00 22,800.00 Operations 162,624.00 157,050.00 $9,000.00 Supplies 36,500.00 39,174.00 $5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 366,900.00 397,088.00 $39,000.00 elf applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: Consolidated HIHR Permanent Supportive Housing Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council • Staff appointed by a member of the Council O The Mayor O The Managing Director 0 The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 0 If no conflicts exist,check here. �� 2021/01/28 Sig ture of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name:Consolidated HIHR Permanent Supportive Housing Programs 11.Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s)pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we)understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we)understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION Pt 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name:Consolidated HIHR Permanent Supportive Housing Programs 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ifor122it, 2021/01/28 Sig ture of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: Consolidated HIHR Permanent Supportive Housing Programs 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Managing, Comprehensive Assessments,and Individual Service Plan(ISP). 100% Health/Mental Health/substance Abuse Treatment Services. 100% Life Skills Training at HIHR Programs and as well with other Partners Providers in the Community 90% Maintain Housing and at the exit of HIHR Program to obtain and Maintain Permanent Housing. 70% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000.00 Professional Fees Operations 9,000.00 Supplies 5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 39,000.00 Additional Council directives regarding award: Please find Attached: •HIHR_RMAP_GrantAward Letter 20201201 •HIHR_HICty_PSH_FY2021-22_NorProfit_Grants_Letterof Explanation_20210128 EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 er Hawai`i Island Home for Recovery, Inc. Transitional&Permanent Supportive Housing Programs Kitchen Pantry Programs Healing our neighbors in need..! C)P COUNTY OF HAWAII Non-Profit Grant FY2021-22 ATTACHMENT EXIBIT I LETTER OF EXPLANATION HAWAII ISLAND HOME FOR RECOVERY, INC. HIHR Consolidated HIHR Permanent Supportive Housing Program Non-Profit Grant Application All Sections Reference: 1. Prior Year Award of County Nonprofit Grant Program Funds and all Other Sections: Accumulativeness Budgets FY18-19_FY19-20 FY18-19_PSH1 $7,613 + PSH2 $6,300 + PSH3 $6,300 Total Budgets = $20,213.00 FY19-20_PSH1 $9,144 + PSH2 $7,108 + PSH3$7,869 Total Budgets = $24,121.00 HIHR was granted authorization by HUD Continuum of Care CoC—NOFA FY2018 to implement the consolidation of the three Permanent Supportive Housing Programs operated by HIHR (PSH 1, PSH 2, PSH 3) in to one single Program: Consolidated HIHR PH 1 FY18 Operating FY2019-20 and beyond. Therefore, HIHR is also submitting to County of Hawaii Non-Profit Grant FY2021-22 one single Permanent Supportive Housing Program which includes the same level of contractual obligations, specifications, and conditions of services as the three prior Programs now merge in to one. All information submitted to the County of Hawaii Non-Profit Grant FY2021-22 includes the summaries of all two previous Grants FY18-19 FY19-20. Mahalo Nui Loa...! For your Consideration, Understanding and Assistance. Helping our Neighbors in Need..! 'Mahalo Nui Loa,for Supporting H/HR Mission Allowing us to Share the Continuum Deve%Pmentand Enhancement of our Communities" 440 Kapiolapi St.Hilo H(96720.OFF 808-9544852•Fax8o8-9355789+• hrehilirccove ry.org•www.hilirecovery.org Hawaii Island Home for Recovery, Inc. HIHR HIHR Kitchen & Pantry Food Outreach Programs 125 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Kitchen & Pantry Food Outreach Programs Agency Director: Rita Sandi Palma Phone No.:(808 )640 —9442 Contact Person: Rita Sandi Palma Phone No.:(808)934 —7852 Mailing Address: Address: Address: 440 Kapiolani St. City,ST,Zip Hilo, HI. 96720-3937 Facility Address: Address: Address: Same City,ST,Zip Email Address: admin@ hihrecovery.org Fax No.: (808 ) 935 —7894 Accountant/CPA: Alex J. Smith Phone No.:(808) 257 —6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. city,s-r,zip Honolulu, HI. 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 0 Puna Hamakua ❑■ North Kona 0 South Hilo ■❑North Kohala 0 South Kona 0 North Hilo 0 South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑Youth 0 Victims of Crimes ❑ Culture and the arts 0 Aged 0 Victims of Health or Social Crises ❑� Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Kitchen & Pantry Food Outreach Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 7,925.00 7,900.00 14,625.00 2.Agency Mission Statement: HIHR Mission is to Serve the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing, Supportive Permanent Housing and long-term Permanent Housing, improving their life's and general skills,increasing personal income, enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models, as well as Coordinated Data Entry System utilizing VI-SPDATand the Housing First Model Approached. 3.Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Shelter Housing Services since 2006,and Permanent Supportive Housing Services since 2011,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals. Additionally, since 2008 also providing Kitchen and Pantry Food Programs. HIHR utilizes quick books software for financial tracking, which is subcontracted, to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns.HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders, dual diagnosis, physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals, asses and creates Individualized Service Plans(ISP)including case management,job training,job placement, substance abuse/mental health treatment,healthcare, living skills,financial training, education, housing resources, entitlements,parenting, domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment, services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island, a caring living environment that helps restores some individuals to a sounder more balance mind, body and spirit,to live independently. 4.Total Budget&Position Count: Total Program Budget: 23,000.00 Total Program Position Count: 1 FT,1PT Total Agency Budget: 1,760,165.00 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Food Outreach Programs 5.Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate HIHR Kitchen&Pantry Food Outreach Programs 1,000.00 Hawaii Island United Way 2,000.00 County of Hawaii Non-Profit Grants 20,000.00 TOTAL: 23,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County,Institutional,public and or Private Entities. HIHR secured additional funding FY2019and FY2020with Hawaii Island United Way national campaign for their Emergency Food Shelter Programs EFSP Phases 35 and 36 respectably. Currently additional funding FY2021 for Emergency Food Shelter Programs EFSPPhases 37 and Cares Act. HIHR annual budget FY2007was just over 150K currently FY2020 was over 1.7M 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description, promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind, body and spirit. HIHR program goals greatly increase the success of residents when complemented with additional benefits like the Kitchen and Pantry Food Programs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Food Outreach Programs 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide Hot Serve Meals as per funds availability to program residents and others. 100% Provide Bag Meals as per funds availability to program residents and others. 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 3,000.00 4,000.00 4,000.00 Professional Fees Operations 3,000.00 3,000.00 Supplies 19,000.00 16,000.00 13,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 21,000.00 23,000.00 20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Food Outreach Programs o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council El Staff appointed by a member of the Council O The Mayor O The Managing Director O The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: CI If no conflicts exist,check here. 2021/01/28 SignaMfgl"t44- Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Food Outreach Programs 11.Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s)pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we)understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,complete,and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Food Outreach Programs li.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. fidlose_ 2021/01/28 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Food Outreach Programs 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide Hot Serve Meals as per funds availability to program residents and others. 100% Provide Bag Meals as per funds availability to program residents and others. 100% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 4,000.00 Professional Fees Operations 3,000.00 Supplies 13,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 20,000.00 Additional Council directives regarding award: Please find Attached: •HIHR RMAP GrantAward Letter 20201201 EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 awai i Island Home for Recovers, In Transitional&Permanent Supportive Housing Programs Kitchen Fy Pantry Programs '0,, Healing our neighbors in need COUNTY OF HAWAII Non-Profit Grant FY2021-22 ATTACHMENT EXIBIT I LETTER OF EXPLANATION HAWAII ISLAND HOME FOR RECOVERY, INC. HIHR Consolidated HIHR Permanent Supportive Housing Program Non-Profit Grant Application All Sections Reference: 1. Prior Year Award of County Nonprofit Grant Program Funds and all Other Sections: Accumulativeness Budgets FY18-19 FY19-20 FY18-19_PSH1 $7,613 + PSH2 $6,300 + PSH3$6,300 Total Budgets = $20,213.00 FY19-20_PSH1 $9,144 + PSH2 $7,108 + PSH3 $7,869 Total Budgets = $24,121.00 HIHR was granted authorization by HUD Continuum of Care CoC— NOFA FY2018 to implement the consolidation of the three Permanent Supportive Housing Programs operated by HIHR (PSH 1, PSH 2, PSH 3) in to one single Program: Consolidated HIHR PH 1 FY18 Operating FY2019-20 and beyond. Therefore, HIHR is also submitting to County of Hawaii Non-Profit Grant FY2021-22 one single Permanent Supportive Housing Program which includes the same level of contractual obligations, specifications, and conditions of services as the three prior Programs now merge in to one. All information submitted to the County of Hawaii Non-Profit Grant FY2021-22 includes the summaries of all two previous Grants FY18-19_FY19-20. Mahalo Nui Loa...! For your Consideration, Understanding and Assistance. Helping our NehborsinNeed..! Mahalo Nui Loa,for Supporting HIHR Mission Allowing us to Share the Continuum DevelopmentandEnhancement of our Communities" 'too Kapiolarti St Hilo HI 94720.Off 808-954-7852•Fax 8o8-935 7894•hihrohihr - ery.orr•www.hihrecovexy.org Hawaii Island Home or Recovery, Inc. HIHR HIHR Transitional Housing Program 126 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Transitional Housing Program Agency Director: Rita Sandi Palma Phone No.:(808 )640 —9442 Contact Person: Rita Sandi Palma Phone No.:(808)934 —7852 Mailing Address: Address: Address: 440 Kapiolani St. city,s-r,Zip Hilo, HI. 96720-3937 Facility Address: Address: Address: Same City,ST,Zip Email Address: admin@ hihrecovery.org Fax No.: (808 )935 —7894 Accountant/CPA: Alex J. Smith Phone No.:(808) 257 —6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. City,ST,zip Honolulu, HI. 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna 0 Hamakua ❑■ North Kona ❑■ South Hilo Q North Kohala ❑■ South Kona 0 North Hilo Q South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑Youth g Victims of Crimes ❑ Culture and the arts El Aged 0 Victims of Health or Social Crises Q Needs of the poor Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 1.Prior Year Award of County Nonprofit Grant Program Funds: FY18-19 FY19-20 FY20-21 7,425.00 9,300.00 12,500.00 2.Agency Mission Statement: HIHR Mission is to Serve the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing, Supportive Permanent Housing and long-term Permanent Housing, improving their life's and general skills,increasing personal income, enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models, as well as Coordinated Data Entry System utilizing VI-SPDATand the Housing First Model Approached. 3. Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Shelter Housing Services since 2006,and Permanent Supportive Housing Services since 2011,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals. Additionally, since 2008 also providing Kitchen and Pantry Food Programs. HIHR utilizes quick books software for financial tracking,which is subcontracted, to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns.HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders, dual diagnosis, physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals, asses and creates Individualized Service Plans(ISP)including case management,job training,job placement, substance abuse/mental health treatment,healthcare, living skills,financial training,education, housing resources, entitlements,parenting, domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide, State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island, a caring living environment that helps restores some individuals to a sounder more balance mind, body and spirit,to live independently. 4.Total Budget&Position Count: Total Program Budget: 232,972.00 Total Program Position Count: 4 Total Agency Budget: 1,760,165.00 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 5.Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State Of Hawail-DHS-HPO 157,252.00 HIHR-Program Fees 29,220.00 Hawaii Island United Way 5,000.00 Other Funds 2,500.00 County of Hawaii Non-Profit Grant 39,000.00 TOTAL: 232,972.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County,Institutional,public and or Private Entities. HIHR active searching history clearly shows the development and expansion of our agency programs like Transitional Shelter Housing Services offered with funding from the State of Hawaii-DHS-HPO departments Since FY2007—FY2011 with renewal funding from FY2011—FY2015 and supplementals contracts FY 2016-17,later from FY2017—FY2021 contracts, and currently FY2020—2024 with annual contract renewal agreements. HIHR annual budget FY2007was just over 150K currently FY2020 was over 1.7M 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals, as stated above in the Mission Statement and Program Description, promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind, body and spirit. As participants are assessed,the Case Manager coordinates HIHR resources and community-based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager promotes the participation in a variety of programs that improves housing stability. HIHR Case Manager/Care Coordinator maintains bi-weekly meetings to process and follow-up activities, also conduct team meetings with providers including probation officers, mental health,substance abuse and medical case managers as part of the support system to follow-up with the goals and objectives of the Individualized Service Plan(ISP) enhancing their well-being. Most chronically homeless population deals with dual diagnosis (substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment, HIHR makes referrals to job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income and stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Case Managing,Comprehensive Assessments,and Individual Service Plan(ISP). 100% Health/Mental Health/substance Abuse Treatment Services. 100% Life Skills Training at HIHR Programs and as well with other Partners Providers in the Community. 90% Maintain Housing and at the exit of HIHR Program to obtain and Maintain Permanent Housing. 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 118,340.00 135,011.00 25,000.00 Professional Fees 16,233.00 17,600.00 Operations 57,579.00 61,221.00 9,000.00 Supplies 9,200.00 19,140.00 5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 201,352.00 232,972.00 39,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ® The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist,check here. 1 flange._ • A 2021/01/28 Sign ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 11.Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment,property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we)understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 2021/01/28 Signatur of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Housing Program 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Managing, Comprehensive Assessments,and Individual Service Plan(ISP). 100% Health/Mental Health/substance Abuse Treatment Services. 100% Life Skills Training at HIHR Programs and as well with other Partners Providers in the Community 90% Maintain Housing and at the exit of HIHR Program to obtain and Maintain Permanent Housing. 70% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000.00 Professional Fees Operations 9,000.00 Supplies 5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 39,000.00 Additional Council directives regarding award: Please find Attached: •HIHR_RMAP_GrantAward Letter 20201201 EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 awai`i Island Home for Recovery, lnc Transitional&Permanent Supportive Housing Programs Kitchen&Pantry Programs Healing our neighbors in need..! COUNTY OF HAWAII Non-Profit Grant FY2021-22 ATTACHMENT EXIBIT I LETTER OF EXPLANATION HAWAII ISLAND HOME FOR RECOVERY, INC. HIHR Consolidated HIHR Permanent Supportive Housing Program Non-Profit Grant Application All Sections Reference: 1. Prior Year Award of County Nonprofit Grant Program Funds and all Other Sections: Accumulativeness Budgets FY18-19_FY19-20 FY18-19_PSH1 $7,613 + PSH2 $6,300 + PSH3 $6,300 Total Budgets = $20,213.00 FY19-20_PSH1 $9,144 + PSH2 $7,108 + PSH3 $7,869 Total Budgets = $24,121.00 HIHR was granted authorization by HUD Continuum of Care CoC— NOFA FY2018 to implement the consolidation of the three Permanent Supportive Housing Programs operated by HIHR (PSH 1, PSH 2, PSH 3) in to one single Program: Consolidated HIHR PH 1 FY18 Operating FY2019-20 and beyond. Therefore, HIHR is also submitting to County of Hawaii Non-Profit Grant FY2021-22 one single Permanent Supportive Housing Program which includes the same level of contractual obligations, specifications, and conditions of services as the three prior Programs now merge in to one. All information submitted to the County of Hawaii Non-Profit Grant FY2021-22 includes the summaries of all two previous Grants FY18-19_FY19-20. Mahalo Nui Loa...! For your Consideration, Understanding and Assistance. He/ping our Ne(hbor5 in Need...! Mahalo Nui Loa,for Supporting HIHR Mission Allowing us to Share the Continuum Development and enhancement of our Communities' 440 Kapiolarti St Hilo Hf 96720.Off 808-93+7852•Fax 808-935 789+•hihrehihrecovery.orr•www.hihrewvery.org i°lawai`i Rise Foundation Family Assessment Center- Ulu Wini 128 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name:Family Assessment Center- Ulu Wini Agency Director: Breeani Sumera-Lee Phone No.:(808 ) 494 —7489 Contact Person: Toni Ann Symons Phone No.:( 808) 319 —2367 Mailing Address: Address: 11 Silva Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 73-4180 Ulu Wini PI. Address: City,ST,Zip Kailua Kona, HI 96740 Email Address: tsymons.uluwini@gmail.com Fax No.: ( 808 )319 —2365 Accountant/CPA: Monir Zaman, CPA Phone No.:( 808 )315 —2727 Firm (if applicable): Hawaii Tass Mailing Address: Address: 614 Kilauea Ave. City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas to Be Served:(One or more can be checked) ❑ Puna ❑ Hamakua ❑■ North Kona ❑South Hilo A North Kohala A South Kona ❑ North Hilo ['South Kohala Q Ka`u Services or Activities to Be Provided: (One or more can be checked) ❑� Educational concerns ❑� Youth 0 Victims of Crimes ❑ Culture and the arts ❑■ Aged ❑Victims of Health or Social Crises ❑A Needs of the poor ❑■ Physical/Emotional Disabilities Public Health and Welfare of the People and therEnvironment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name:Family Assessment Center- Ulu Wini 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 0 2. Agency Mission Statement: The Hawaii Rise Foundation's mission is to provide services and programs which give opportunities for vulnerable, moderate,and low-income children and families to become financially independent and contributing members of society. We are serving our community in creative ways by addressing issues such as homelessness,domestic violence, housing, food security,education, employment,and financial stability by bringing services to people in the communities where they live. Many people we serve lack transportation needed to access available services so building capacity where they live builds confidence,and trust and empowers them to move forward. ( 3. Program Description: Last year Ulu Wini working in collaboration with the State,was awarded funding for a Family Assessment Center(FAC). This funding is through the Ohana Zones program and is designed to address homeless issues families face in West Hawaii.The FAC is a centralized access point where any family with minor children who are homeless or may be on the verge of homelessness can get assistance.At the FAC they can receive the support,once assigned,of a Case Manager who will determine their needs. Once their situation is assessed and a determination is made,the work begins. It could be the replacement of personal documents or help with child-care so a parent can work. It could be a car repair so they can get to work and pay their rent. It may be help with housing applications, a call to a landlord,connection to emergency shelter or help in a domestic violence situation.With our on-site navigation center,we can provide services to families quickly.Our staff may offer budgeting, renter education,benefits enrollment, or life skills counseling.Staff can focus on the rapid development of a housing plan and identify barriers while connecting to community services and supports. In the last six months we have found no programs that can help with things we have identified in our proposal,quickly.Over the last 8 months we have identified additional issues that contribute to homelessness and additional supports that could help to prevent homelessness.We are looking for funding to assist our families so they can stabilize quicker and to give staff the ability to start implementing the supports immediately once the assessment of needs and barriers are completed. Those who live in low-income housing do not qualify for the standard rental assistance or utility programs and we know of no funders who provide help with car repairs, registration and other family basics like we are proposing. Those who benefit from our program will be coming from Domestic Violence shelters, homelessness,family homes and the street.We will be housing the most vulnerable first based on the VI-SPADT tool being used by all homeless providers in the State of Hawaii. 4. Total Budget& Position Count: Total Program Budget: 38,000.00 Total Program Position Count: 0 Total Agency Budget: Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise-Foundation Program Name:Family Assessment Center- Ulu Wini 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii-Ohana Zones Funding $138,000.00 In-Kind donations-household goods,food,other supplies for families $20,000.00 Care Portal-Community Partners $10,000.00 Pay it Forward-Community Partner $5,000.00 Woman's Fund $5,000.00 TOTAL: $178,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to look for other grant opportunities and partnerships to assist us with this work.We anticipate that when we get closer to the end of the eviction moratorium there will be funding opportunities available to programs like ours to help our community and we will be actively applying for any of those funds when we see them available.Our staff is involved in the local homeless committees and we will also look for partnerships there as well. 7. Program Objectives Using County Nonprofit Grant Program Funds: We are asking the County to help us by providing funds for services to help families get on their feet.With gift cards we can provide gas,food, clothing, and other things needed based upon their initial needs assessment when they arrive to our housing program.We have seen families who need assistance with car repair and tires so a parent can continue to be employed.Some of our parents have needed help with"transitional"childcare assistance while waiting for their regular childcare assistance to be processed through the state funded program when starting a new job or returning to work after COVID.We have also seen a need for help with rental deposit, rental arrears,utility arrears and utility deposits. Not all people were able to qualify for programs funded by CARES money and without the eviction moratorium they would be new homeless families on the street.We want to be prepared to help those who are on the edge and could be on the street at any time.There has been a great increase in rent costs and from recent data provided by the Community Alliance Partnership(CAP)we know in order to house our homeless population and to prepare for the future we need an additional 13,000 units! If we can provide support through our program by thinking out of the box and being able to provide help with the barriers we have identified,then we can help to keep people employed and housed. We will monitor expenses closely and make sure things are provided to those who are assessed to have the highest needs.And the Program Manager will work closely with the community and staff to make sure it is done equitably and not as a band-aid but as a step to stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Family Assessment Center- Ulu Wini 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are you measuring what happens for the Participants after they hove participated in your program?Describe,be specific.) See Attached Attach additional pages, as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 9,750.00 Equipment 0 Other: Rental Assistance - Arrears 5,000.00 Other:Rental Deposit 5,000.00 Other:Utility Deposit 1,000.00 Other:Utility Arrears 3,000.00 Other:Childcare Assistance 4,250.00 Other: Car Repair/Supplies 5,000.00 Other: Car Registration, Safety Check 2,000.00 Administration Fees 3,000.00 TOTAL $38,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Family Assessment Center- Ulu Wini 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council. ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel - Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: di If no conflicts exist, check here. I / 2.91 2°2 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Family Assessment Center- Ulu Wini 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Family Assessment Center- Ulu Wini 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance, or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ?526 i 119-120 21 Signature of Authorized Person Date wX v&' 9 k VeAr5r. Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Family Assessment Center- Ulu Wini 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 COUNTY OF-HAWAII NON-PROFIT GRANT APPLICATION FY: 2021-2022 Family Assessment Center— Ulu Wini 8. Table 1 — Program Performance Measures 1. For the period July 1—December 30, 2021 we will provide support in all budget categories. 2. For the period December 31—June 30, 2022 we will provide support in all budget categories with remaining funds. Expected Results: • Barriers will be removed, and housing stability maintained with the necessary financial support identified in the FAC assessment. Health and safety protected with utility assistance. • Greater employment opportunities, stability. • Safe, working, legal automobile for transportation. • Childcare will not be a barrier to employment. • Hawaii Rise Foundation Malama Na Keiki After-School and Weekend BackPack Food Program 129 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name:Malama Na Keiki After-School and Weekend BackPack Food Program Agency Director: Breeani Sumera-Lee Phone No.:(808 ) 494 —7489 Contact Person: Toni Ann Symons Phone No.:(808 ) 319 —2367 Mailing Address: Address: 11 Silva Street Address: City,ST,zip Hilo, HI 96720 Facility Address: Address: 73-4180 Ulu Wini PI. Address: City,ST,Zip Kailua Kona, HI 96740 Email Address: tsymons.uluwini@gmail.com Fax No.: (808 ) 319 —2365 Accountant/CPA: Monir Zaman, CPA Phone No.:(808) 315 —2727 Firm (if applicable): Hawaii Tass Mailing Address: Address: 614 Kilauea Ave. city,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua 0 North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑■ Victims of Health or Social Crises • Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 $20,000.00 2. Agency Mission Statement: The Hawaii Rise Foundation's mission is to provide services and programs which give opportunities for vulnerable, moderate and low-income children and families to become financially independent and contributing members of society. We are serving our community in creative ways by addressing issues such as homelessness,domestic violence, housing, food security,education,employment and financial stability by bringing services to people in the communities where they live. Many people we serve lack transportation needed to access available services so building capacity where they live builds confidence,and trust and empowers them to move forward. 3. Program Description: We are proposing to deliver our third weekend backpack food program to the children who live at Na Kahua Hale 0 Ulu Wini. Eighteen of our families at Ulu Wini live in Transitional Housing coming directly from homelessness. Five families are fleeing domestic violence and are receiving support in a safe environment.Seventy-one of our families are considered very-low income and pay only 30%of their income towards their housing.98%receive SNAP benefits and all school-age children receive free breakfast and lunch when school is open. Currently there are 215 children at Ulu Wini. They are always so hungry!With COVID stay at home orders in place we were not able to provide programs as we did the year before. But having access to funds from the FY 2020-2021 GIA allowed us to serve children food daily along with weekend food.Our kids were not fully engaged with school and food programs as many families struggled with access due to language and technology challenges.With a computer donation received,and"my-fi"from the Intermediate school, families have had greater access this school year.We continue to have a solid core of tenant volunteers who will help us select the food and get it ready for distribution. This program will give access to healthy foods as we make sure we supplement with food from community gardens and the Food Basket. We offer an after-school tutoring program now following all CDC guidelines and these funds will allow us to provide food at this level as well.We will include extra food in the packs so their siblings who are not school-age won't be left out. 4.Total Budget& Position Count: Total Program Budget: 30,000.00 Total Program Position Count: 0 Total Agency Budget: Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Volunteer help packing BackPacks-960 hours @$11.00per hour- $10,560.00 In-Kind Fruit&Vegetable Donation-St.Michaels Church-4 x per week @$150.00 value per week $6750.00 Honaunau Market Fruit&Vegetable Donation-1 x per month @$125.00 $1500.00 FB Fundraising and direct donor requests $3,000.00 TOTAL: $21, 810.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to work closely with the Food Basket who has periodically donated USDA food for our families.We also have accepted in-kind support form our partner the Boys and Girls Club, Big Island whose staff has helped us distribute food, purchased food for our kids and throughout last year provided a limited amount of hot meals to those who needed it most. We continue to use some of our set-aside program funds to purchase food at the Food Basket as well. We also hope to seek funding through Hawaii Community Foundation later on this year and will be paying close attention to see if any additional CARES funding will be available with this new administration. We also feel comfortable asking donors for help in a pinch. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objective is always the same,to feed hungry children after school and on the weekends at Ulu Wini.They will receive approximately 7 protein rich meals to cover breakfast,a lunch snack and a hot evening meal.We will also include fruit and vegetables and whatever extras we receive from the Food Basket that week.We will provide extras for the non school-age children.We will be seeking ongoing feedback from the kids and allow them to help us choose and try new things.With the challenges our families faced with COVID including loss of employment and food insecurity,we were fortunate to have this dedicated funding stream to feed our kids. We know this year will continue to be challenging and we want to continue to fill the empty tummies with food so no child goes hungry. It also allows us to check on the kids to make sure they are doing okay. They feel comfortable telling us when they are hungry and we can respond immediately to their needs. This is an example of some of the items included in the distribution and after-school; Chicken with rice soup(1 7.2 ounce can), Beef ravioli in tomato and meat sauce(1 7.5 ounce)Cut green beans(1 8 ounce can)applesauce(1 4 ounce cup)Crispix cereal(1 0.75 ounce box)Seaweed and beef jerky,fresh fruit,fresh vegetables. Ramen noodles,Wheat cracker(2 count package)and cheese, 1%milk(2 8 ounce cartons)Grape fruit strip(1 0.91 ounce package)Tropical adventure fruit snack mix(1 ounce package).We have provided Hot Pockets,fresh organic juice, dried fruit that we have involved our kids in preparing,waffles and peanut butter, popcorn and more. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) See attached Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 0 Professional Fees 0 0 Operations $500.00 $1000.00 Supplies $500.00 $2000.00 Equipment 0 0 Other: After-school and weekend Food $16,000.00 $22,000.00 Other: Packs for Food $1000.00 $2000.00 Other: Administrative Support $2000.00 $3000.00 Other: Other: TOTAL $20,000.00 $30,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor O The Managing Director O The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ►i' If no conflicts exist, check here. 139-6L- 0112-i Iozl Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 1 ' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Malama Na Keiki After-School and Weekend BackPack Food Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 COUNTY OF HAWAII NON-PROFIT GRANT APPLICATION FY: 2021-2022 Malama Na Keiki After-School and Weekend Food Program 8. Table 1 — Program Performance Measures 1. 300 children will receive healthy weekend food in a pack for approximately 45 weekends to start one month after funds are received. This pack will include two healthy breakfast items,two healthy lunch items and three additional protein meals for evening snack and extras for the family when available. We will also include extra fruit and vegetables sourced and donated from a local vendor. Expected Results: • Children will report they were less hungry on the weekends. • Children will exhibit, through anecdotal evidence, improved academic performance and more energy when they return to their academics. • Parents and children will be exposed to healthier food choices and depend less on sodium- filled, processed food. They will try new foods which may affect food choices during the week. 2. Information about the food in the pack was well-received during our first program so we will continue this educational piece and include recipes. Budgeting tips and suggestions for cutting food costs will be provided. Expected Results: • Families will report benefits to their children from the after-school and backpack program. • Families will report less hunger-in their households on the weekend. • SNAP benefits will last longer with extra food in the household. 3. Up to 10 volunteers will commit to packing the packs, and some will agree to deliver the packs to the households with our kids helping to pack and deliver. Expected Results: • This will allow for timely distribution. • Accurate data collection 4. Surveys will be conducted with families to gain feedback on food and the program. Hawaii Rise Foundation Rise-UP Domestic Violence Housing Program 130 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program Agency Director: Breeani Sumera-Lee Phone No.:(808 )494 —7489 Contact Person: Toni Symons Phone No.:(808 )319 —2367 Mailing Address: Address: 11 Silva St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 73-4180 Ulu Wini PI. Address: City,ST,Zip Kailua Kona, HI 96740 Email Address: tsymons.uluwini@gmail.com Fax No.: (808 )319 —2365 Accountant/CPA: Monar Zaman, CPA Phone No.:(808 ) 315 —2727 Firm (if applicable): Hawaii Tass Mailing Address: Address: 614 Kilauea Ave. City,ST,Zip Hilo, YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request far County Nonprofit Grant Program Funds: hi 96720 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑■ North Kona ❑South Hilo 0 North Kohala Q South Kona ❑ North Hilo ❑■ South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑■ Victims of Crimes ❑ Culture and the arts ❑■ Aged ❑� Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $23, 775.00 $42,650.00 $68,750.00 2.Agency Mission Statement: The Hawaii Rise Foundation's mission is to provide services and programs which give opportunities for vulnerable, moderate, and low-income children and families to become financially independent and contributing members of society. We are serving our community in creative ways by addressing issues such as homelessness, domestic violence,housing, food security, education,employment, and financial stability by bringing services to people in the communities where they live. Many people we serve lack transportation needed to access available services so building capacity where they live builds confidence,and trust and empowers them to move forward. 3. Program Description: Domestic violence is often a contributor or cause of homelessness. Escaping abusive situations mean leaving the residence where the abuse is occurring,and most victims are unable to find shelter through friends,family or available community resources.When a person finally decides to leave a volatile situation;it is most often with just their clothes on their backs, nothing more.When they enter our housing program,we must start building safety and hope for them.We will provide a safe and healthy place to live and staff to help them fill basic needs.We will help with new documents,apply for benefits,and whatever else needed to stabilize.We have seen situations where children have not had immunizations or well-baby checks or have never seen a dentist. Hawaii Rise is a beneficiary of HUD funding to help those families fleeing domestic violence stabilize their housing situation.We have been awarded funding for two-years to provide transitional housing and once stabilized, rental assistance along with a Housing Based Case Manager to"walk-alongside"the family on their road to a healthy home environment. Our HUD funding is limited to the direct supportive service by a Case Manager and funds for rental assistance.We are asking the County to help us by providing funds for enhancement services to help these families get on their feet.With gift cards we could provide gas,food, clothing and other things needed based upon their initial needs assessment when they arrive to our housing program.Those who benefit from our program will be coming from Domestic Violence shelters,homelessness,family homes and the street.We will be housing the most vulnerable first based on the VI-SPADT tool being used by all homeless providers in the State of Hawaii.Those families in the DV Shelters are considered homeless under HUD rules and will be prioritized as such.They will be brought into the Ulu Wini transitional program for 90 days while we find them a place to live and make arrangements to pay their rent/rental deposits as needed.Our goal is to provide what they need to stabilize. Due to our limits on the HUD budget, having additional funds to help these families will ease some of their worry and help them to focus on safety,their children and their future. 4.Total Budget,& Position Count: Total Program Budget: $30,000.00 Total Program Position Count: 0 Total Agency Budget: $200,000.00 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise'Foundation Program Name: Rise-UP Domestic Violence Housing Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Direct donor fundraising $5,000.00 Women's Fund $5,000.00 In-Kind Donations-Furnishings and other household goods $10,000.00 Hawaii Community Foundation-Atherton Proposal $5,000.00 TOTAL: $25,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to build our donor base to increase donations and look for other grant opportunities to build sustainability. The HUD funding for this program is renewable year-to-year for up to five years as long as we deliver our program according to HUD guidelines.The Rise-UP program has seen an increased need to add more beds because of the pandemic and the uptick in domestic violence. It has been challenging finding housing due to the moratorium and we have seen a decrease in donations but we continue to tell our story and seek funding,especially now that we have new leadership at the federal level,we are hopeful that more housing will be added to the inventory and funding for rental assistance and other supports. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our program objectives remain the same because Domestic Violence, its victims and the trauma does not change.We want to address immediate needs which includes the ability to purchase gas cards,food certificates,gift cards for clothing and household goods and provide help to those who may need to relocate to the mainland for safety reasons.We would also like to help with car repairs, medical extras and other items to be determined as we move forward with this much needed program.With families moving to their own place with rental assistance from the Rise-Up program, it woild also help to provide the basic material needs like school supplies for the children, new linens and towels for their home.We will monitor expenses closely and make sure things are provided to the most needy and their Case Manager will work closely with the community and staff to make sure it is done equitably. Our funding from HUD only allows for rental assistance and supportive services through Case Management so having these enhancement funds available to us will make the transition to stability much easier for those fleeing domestic violence to their own new, healthy lives,especially for the children EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How ore youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) See attached Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $13,000.00 $13,000.00 Equipment $2,500.00 Other: Rental Assistance $4,000.00 $80,000.00 $6,000.000 Other: Case Management & Supportive Services $53,420.00 Other: Car Repair $3,000.00 $4,500.00 Other: Administrative Costs $4,000.00 $10,981.00 $3,000.00 Other: Airfare $3,500.00 $3,500.00 TOTAL $30,000.00$144,401.00$30,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program sae ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed.,One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director El The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ►!l, If no onflicts exist, check here. 1129/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. WZI Signature of Authorized Person Date gAeCkniCi D VeekvY Title/Position of Authorized Person EXHIBIT-A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Rise-UP Domestic Violence Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL I Council directives regarding arding award:l; EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 COUNTY OF HAWAII NON-PROFIT GRANT APPLICATION FY: 2021-2022 Malama Na Keiki After-School and Weekend Food Program 8. Table 1 — Program Performance Measures 1. 300 children will receive healthy weekend food in a pack for approximately 45 weekends to start one month after funds are received. This pack will include two healthy breakfast items, two healthy lunch items and three additional protein meals for evening snack and extras for the family when available. We will also include extra fruit and vegetables sourced and donated from a local vendor. Expected Results: • Children will report they were less hungry on the weekends. • Children will exhibit, through anecdotal evidence, improved academic performance and more energy when they return to their academics. • Parents and children will be exposed to healthier food choices and depend less on sodium- filled, processed food. They will try new foods which may affect food choices during the week. 2. Information about the food in the pack was well-received during our first program so we will continue this educational piece and include recipes. Budgeting tips and suggestions for cutting food costs will be provided. Expected Results: • Families will report benefits to their children from the after-school and backpack program. • Families will report less hunger in their households on the weekend. • SNAP benefits will last longer with extra food in the household. 3. Up to 10 volunteers will commit to packing the packs, and some will agree to deliver the packs to the households with our kids helping to pack and deliver. Expected Results: • This will allow for timely distribution. • Accurate data collection 4. Surveys will be conducted with families to gain feedback on food and the program. Il1awai°i Rise Foundation Together We Can 131 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hawaii Rise Foundation Program Name:Together We Can Agency Director: Breeani Sumera-Lee Phone No.:(808 )557 —0880 Contact Person: Breeani Sumera-Lee - Phone No.:(808 )557 —0880 Mailing Address: Address: 11 Silva Street Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Address: 11 Silva Street City,ST,zip Hilo, Hawaii 96720 Email Address: breeani@hawaiirisefoundation.com Fax No.: ( ) — Accountant/CPA: Monir Zaman, CPA Phone No.:(808 ) 315 —2727 Firm (if applicable): Hawaii Tass Mailing Address: Address: 614 Kilauea Ave City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 185,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑� Puna Q Hamakua Q North Kona 0 South Hilo ❑■ North Kohala 0 South Kona El North Hilo 0 South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑■ Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Together We Can 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $23,775.00 $42,650.00 $68,750.00 2.Agency Mission Statement: The Hawaii Rise Foundation's mission is to create opportunities for vulnerable,or moderate and low-income families, children and elderly by providing educational services, programs and support. We are serving our community in creative ways through addressing issues such as homelessness,domestic violence, housing,food security, education, employment and financial stability through our services. 3. Program Description: Currently we are seeing the struggle of many kupuna who are now without food now that CARES funding has ended. We have been in communication with many elderly who we continue to create meal bags and kupuna packs for and we would like to continue to create kupuna packs and meal bags for kupuna and deliver them island-wide during the continuation of this pandemic.We have estimated that if we create a basis of breakfast, lunch and dinner in a'meal bag'then we are able to provide a kupuna/ohana with breakfast, lunch and dinner for 7-9 days. We would do these drops bi-weekly,estimating around$5,000.00 a week for food,to serve around 100 kupuna in that community. We would want to support local stores,within our communities by purchasing fresh fruits and vegetables in these meal bags as well to help sustain our local economy. We believe we could serve 100 kupuna bi-weekly in each district across Hawaii Island to help keep our kupuna fed and healthy. We would love to partner with local farmers and depending on the season,allow kupuna fresh produce from their community gardners as well.Kupuna packs would include snacks,toilet paper, paper towels,sanitizer, etc and meal bags would include canned goods,fruits and vegetables to create up to 7-9 days worth of meals. Due to the incredibly challenging year that 2020 presented us with,it is with great honor that I am able to share that during the most recent and difficult of times,the Hawaii Rise Foundation in partnership with many great teams were able to assist and support our kupuna along with many other community members island wide. The numbers are quite astounding. In partnership with Ola Na Iwi, Hawaii Community Foundation,the Department of Health, HELCO, Hui Malama Ola Na Oiwi, Imiloa Astronomy Center, Big Island Delights,Vibrant Hawaii, Show Aloha Challenge, King Kamehameha Hotel, Seaside Hotels and the Keaukaha General Store we were able to deliver in 2020: 5,000+Kupuna bags(snacks,toilet paper, paper towels,wipes) 2,096 Food bags able to produce 38,428 meals 3,800 hot meals delivered to their homes all across the island 4. Total Budget & Position Count: Total Program Budget: 185,000.00 Total Program Position Count: 3 Total Agency Budget: 200,000.00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name: Together We Can 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Kamehameha Schools 10,000.00 Holomua Community Federal Credit Union 1,000.00 TOTAL: 11,000.00 Attach additional pages,if needed. ort 6. Explain what plans your agency or program has to increase revenues to support this program: Hawaii Rise Foundation has been actively using a program called"catchafire"which is provided to us by Kamehameha Schools. Catchafire is a platform that matches professionals from all over the world,who want to donate their time with nonprofits who need their skills. Currently we have some wonderful professional volunteers who help to share their knowledge and facilitate meaningful opportunities with HRF including a CPA,a Marketing Director and the Senior HR Director for Chevron. We have been utilizing these volunteers to increase our involvement and to grow our platform. Due to limited budgets,we have been blocked to hire certain talents we needed to operate effectively,but with catchafire we are bridging this gap and increasing revenues through learning more about the resources out there,the ways we can be more impactful and having accessible and knowledgable peopel on our team that are helping us to connect to additional partners and likeminded agencies that have helped us to increase our revenues to support our current endeavors. HRF has also been raising awareness through our social media. We are continuing to build our website and our marketing,increasing our donations, maximixing our potential and being able to use funds for simple tings such as flyers, marketing materials and web design. We hope to continue to increase revenues so that we can continue to be a sustainable program. In 2020,we received CARES funding as the Fiscal Sponsor for Vibrant Hawaii and successfully created over 30 resilience hubs island wide providing over 100,000 hot meals. CARES funding ended but we want to continue to feed our elderly. 7. Program Objectives Using County Nonprofit Grant Program Funds: We would like to be able to provide food/meal bags to every community island-wide. We would like to be able to capture data of the kupuna we are serving in each district to be able to provide them with additional help if they need it. We would like to partner with local farmers to provide fresh produce to our kupuna island-wide We would like to provide a variety of fresh fruit and vegetables depending on the season and further educate our community on sustainable agriculture and farm to table style eating. Example:A local farmer in Kaumana grows papaya. This farmer could provide papaya for the community of Hilo.The kupuna who receives this papaya will also receive yogurt along with a short description of the benefits of papaya and the different ways to consume this fruit. This allows kupuna and keiki, many of which live with their kupuna, an opportunity to connect, an opportunity to share,an opportunity to grow and an opportunity to support our local farmers in our communities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name:Together We Can 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) We will rotate island-wide deliveries,keeping track of the names of the kupuna/ohana served We will create a master farmers list of all the farmers in our communities and the produce they grow We will be able to support local stores and local gardens We will keep track of the other needs that kupuna mention,so we can be more impactful We will continue to make kupuna packs see attachment Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 30,000.00 30,000.00 Professional Fees 5,000.00 5,000.00 Operations 5,000.00 5,000.00 Supplies 5,000.00 5,000.00 Equipment Other: Supplies for Kupuna Packs (toilet paper, paper tow( 10,000.00 10,000.00 Other: Food for Meal Bags for Kupuna 130,000.00 130,000.00 Other: UHaul Box Truck for Delivieres + Gas 2,000.00 2,000.00 Other: Other: TOTAL 187,000.00 187,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name:Together We Can 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Breeani Sumera-Lee POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor ▪ The Managing Director ® The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: la If no conflicts exist, check here. 01 27 2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Rise Foundation Program Name:Together We Can 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT'A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hawaii Rise Foundation Program Name:Together We Can 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 672J1. 01 27 2021 Signature of Authorized Person - Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai i Nonprofit Grant Application FY2021-22 Agency Name:Hawaii Rise Foundation Program Name:Together We Can 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result see attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 30,000.00 Professional Fees 5,000.00 Operations 5,000.00 Supplies 5,000.00 Equipment Other: Supplies for Kupuna Packs 10,000.00 Other: Food for Meal Bags for Kup 130,000.00 Other: UHauls for Deliveries + Gas 2,000.00 Other: Other: TOTAL 187,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 COUNTY OF HAWAII NON-PROFIT GRANT APPLICATION FY: 2021-2022 Together We can 8. Table 1 —Program Performance Measures 12. Table 1 —Program Performance Measures 1. We will rotate island-wide deliveries, keeping track of the names of the kupuna/families served. 2. We will create a master farmers list of all the farmers in our communities and the produce they grow. 3. We will be able to support local stores and local gardens. 4. We will keep track of other needs of the elderly. 5. We will continue to make kupuna packs. Projected Results: • Kupuna will be able to have adequate nutrition and have easy to prepare and nutritious. • The master list of all the farmers will be circulated throughout communities so that others will be aware of the local farmers and what/who they can support. • We will be able to pour money into our local stores/gardens/communities to help our local economy at this time. • We will be able to address other needs of our elderly by understanding their needs and being in contact with them more frequently. • We will form better connections with our kupuna so that we will know how to break additional barriers they are facing. • We will allow kupuna the opportunity to stay home and have less risk of exposure by continuing to make kupuna packs with the essentials provided. Hawai'i Society of OB/GYN Hawai'i County OB/GYN Resident Program 132 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name:Hawaii County OB/GYN Resident Program Agency Director: John K Uohara Phone No.:(808 ) 937 —3600 Contact Person: John K Uohara Phone No.:(808 ) 937 —3600 Mailing Address: Address: PO Box 954 Address: city;ST,Zip PeDeekeo, HI 96783 Facility Address: Address: Address: City,ST,Zip Email Address: obgyn96720@hotmail.com Fax No.: ( ) — Accountant/CPA: Necelyn Cabalce, CPA Phone No.:(808) 935 —5404 Firm (if applicable): Taketa, Iwata, Hara & Associates, LLC Mailing Address: Address: 101 Aupuni St. Suite 139 City,ST,Zip Hilo, Hawaii 96720-4260 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $78,400.00 Geographical.Areas To Be Served: (One or more can be checked) ❑f• Puna ❑■ Hamakua 0 North Kona ❑■ South Hilo ❑i• North Kohala ❑■ South Kona ❑■ North Hilo M South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns El Youth ❑Victims of Crimes ❑ Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 0 19,625.00 2.Agency Mission Statement: Mission: To advance the cooperation and interaction of physicians involved in women's health care through life long learning and expand women's health care to the entirety of the state of Hawaii. Vision: To create a platform and awareness of the needs of women in remote and underserved areas of the State of Hawaii. We will focus on being patient centered and culturally sensitive which will result in exceptional outcomes. We will create standards of care for clinical practice for the State of Hawaii through evidenced based knowledge. We will create an advocacy for quality comprehensive women's health care for the State of Hawaii. 3. Program Description: There is a crisis of physician shortage in Hawaii County. A recent study done by UH Manoa estimates our physician shortage to exceeds 200. There is an inequality for women with respect to access and services for complex womens healthcare. Resident physicians(3rd&4th year)will rotate through Hilo Medical Center for a duration of one month. This will total 12 residents over a period of one year. The resident physicians will be exposed to daily office practice,as well as surgeries at Hilo Medical Center. These residents in training will have the opportunity to live,eat and play amongst the people of Hilo. In addition to this lifestyle exposure,they will experience how rural medicine is practiced. A similar program was run at Maui Memorial Hospital. It ran for a period of seven years and resulted in 4 residents locating to Maui County. In the short time that the Hilo project has run,one physician has started practice in August, 2020,and another is actively seeking employment. Hawaii Society of OB/GYN seeks to encourage medical students and residents to consider practice in rural and underserved areas. We will also help support our Hawaii County Residents to pursue a career in medicine. 4.Total Budget& Position Count: Total Program Budget: $152,660.00 Total Program Position Count: 12 Total Agency Budget: $148,760.00 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Wayne Kamitake(ACE Hardware) $2,500.00 John K Uohara,MD $2,000.00 Shippers Wharf Grant $39,000.00 William Fong,MD $1,000.00 Hawaii County Non-Profit Grant $19,625.00 TOTAL: $64,125.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are active in applying for grants and soliciting donations from individuals and private companies. We will be attempting to host a medical conference(pending Covid-19 restrictions). We are hopeful that IMUA:Women's Health will generate addition income for our organization. 7. Program Objectives Using County Nonprofit Grant Program Funds: County Nonprofit Grant Funds will be used to support Resident Physician rotations to Hawaii County. A portion of the funds will be used to support the efforts of the Hawaii Society of OB/GYN. Our primary goal is to bring awareness of the needs of the needs of our rural and underserved communities. We will attempt to do this by hosting a Statewide Conference on the medical needs of Hawaii County. We will involve medical students, resident physicians as well as practicing physicians.Hospital administrators and insurance providers will be invited and encouraged to attend. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide exposure to rural life and living/teaching experiences for 12 resident physicians Statewide-Medical conference on needs of rural communities Participant tracking by project leaders-Evaluation of performance and competency Program participants will have an overall understanding and awareness of rural communities Program participants will have knowledge of quality comprehensive women's health care Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $125,000.00 $125,000.00 $62,500.00 Professional Fees $1,200.00 $1,200.00 Operations $1,500.00 $1,500.00 Supplies Equipment Other: Airfare $3,600.00 $3,600.00 0 Other: Car Rental, Residents, Director, Dept. Chair. $8,160.00 $8,160.00 0 Other: Housing (1,000 mo/per yr) $12,000.00 $12,000.00 $12,000.00 Other: Secretarial Services $1,200.00 $1,200.00 Other: TOTAL $148,760.00 $152,660.00 $78,400.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor The Managing Director • The Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■1 If no conflicts exist, check here. AW4160-14-AA-0( Seki Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment,property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. iwum,egecitAA1/46 tel Signature of Authorized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hiwai`i 'Wildlife Center Native Wildlife Services 133 ticuctii Vinciti-ce Cen4er Native W,td►i{e Serv�c�s County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Wildlife Center Program Name: Native Wildlife Services Agency Director: Linda Elliott Phone No.:(808 )884 —5000 Contact Person: Rae Okawa Phone No.:(808 )884 -5000 Mailing Address: Address: P.O. Box 551752 Address: City,ST,Zip Kapaau, HI 96755 Facility Address: Address: 53-324 Lighthouse Road Address: City,ST,Zip Kapaau, HI 96755-1752 Email Address: development@hawaiiwildlifecenter.org Fax No.: ( ) — Accountant/CPA: Nana Anderson, EA, MBA Phone No.:(808 ) 987 —6762 Firm (if applicable): Kohala Tax LLC Mailing Address: Address: P.O. Box 1514 City,ST,zip Kapaau, HI 96755 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 10,000 Geographical Areas To Be Served: (One or more can be checked) D Puna ElHamakua 0 North Kona 0 South Hilo Q North Kohala J South Kona ID North Hilo 0 South Kohala Q.Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth []Victims of Crimes 0 Culture and the arts D Aged ❑Victims of Health or Social Crises Needs of the poor E Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 klo�uvia i Uri i lc4l i e maker l alive W to ti: e Sem:us County of Hawai`.i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Wildlife Center Pro ram Name: Native.Wildlife Services 1.Prior Year.Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $2,500(County Council Contingency Grant) $10,000(Holomua Hawaii Program) 2.Agency Mission Statement: The mission of the Hawaii Wildlife Center Is to protect,conserve,and aidin the recovery of Hawaii's native wildlife through hands-on treatment,research,training,science education and cultural programs. 3. Program Description: The Hawaii Wildlife Centerspecializes in the rescue,response and hospital care of Hawaii's native birds and bats statewide.The Hawaii Wildlife Center's wildlife hospital is located in Kapaau,on Hawaii island,but the geographic reach of the organization expands islandwide and statewide.Our wildlife program provides and improves wildlife care services available for over 70 different species and subspecies of native birds plus the endangered Hawaiian hoary bat,and expands professional networks in wildlife rehabilitation,conservation and veterinary circles.We also provide a place for the community to turn when assistance with wildlife rescue is needed,as well as a resource that helps remedy injuries or illnesses that arise from.human-wildlife interactions.In most cases,these interactions are accidental,like in the case of vehicle strikes or fishing line entanglement,though there have also been cases that have been targeted and malicious including wounds from gunshots. in addition to saving as many of these affected animals as we can,we also hope to use our patient stories to inspire small changes in behavior that will better protect native species,including using wildlife-safe rodent poisons.minimizing light pollution,and properly disposing of fishing line and debris. 4.Total Budget&Position Count: Total Program Budget: $150,000 Total Program Position Count: 2 Total Agency Budget:.$460,000 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 Hawaii Witdti.ce. Ce&re.( Naktve: Witctl ce &A-vices County of Hawai`.i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Wildlife Center Prow-am Name: Native Wildlife Services 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Grants from Private Foundations 90,000 Corporate Support Agreements 36,000. Donations from Individuals 23,000 Retail Sales 1,000 TOTAL: 150,000 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase,revenues to support this program: Funding is being sought from additional grantors as well as individual donors.Annual fundraising efforts and sales from HWC's retail store at our facility also support our wildlife services.Though our physical store is closed due to COVID,we have been able to open an online store and continue to make sales that way.We also continue to grow our support agreement partnerships,which provides reliable annual support from our corporate partners each year the agreement is active. 7.Program Objectives Using County Nonprofit Grant Program Funds: We are requesting support for our wildlife hospital and rescue operations.With patient numbers increasing as well as the level of case complexity also increasing(i.e.more intenstive-care/long-term patients with fractures or complexhealth issues),it is critical for us tomaintain and build our grant support. Since we are transitioning to full-fledged wildlife hospital and providing more medical procedures(i.e.surgeries)on-site, we are needing to invest in more medical supplies and equipment.In addition,funding support will also help us keep a veterinarian and wildlife technician on staff,keepwildlife feed stocked,and help us keep on top of facility supplies and maintenance,including ongoing:aviary and holding area maintenance. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3.of.8 { (tNOlii N'iildti Cen-Ver gafiive WitdRce. Serv. ces County of Hawai`i Nonprofit °rant Application FY202.1-22 Agency Name: Hawaii Wildlife Center Program Name: Native Wildlife Services 8.TABLE I: What are the measurable performance outcomes that wouldbe achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Total native wildlife(bird and bat)patients provided rescue,medical treatment,andlor rehabilitation 400 Total public calls answered regarding wildlife issues and assistance with appropriate response 750. Attach additional pages as necessary. 9.TABLE Il: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 58,295 75,000 6,500 . Professional Fees 0 1,000 Operations Supplies 12,614 25,000 2,500 Equipment Other: Wildlife Transport 13,245 16,500 Other: Veterinary Services, Diagnostics&Labs 8,307 10,000 1,000 Other: Wildlife Hospital internships 0 1,000 Other: Wildlife Projects (including Oahu Seabird Aid) 12,623 20,000 Other: Reference, Resources &Training 553. 1,500 TOTAL 105,637 150,000 10,000 *lf applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 Nawaii Wit/Alike CmM r t 4ige tNiiclti e servic2S County of Hawaii Nonprofit Grant A plication FY20 l-22 Agency Name: Hawaii Wildlife Center Program Name: Native Wildlife Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sianed,_reaardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that.apply): 0 Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to,an industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: ❑; if no conflicts exist, check here. eicesdt r UtrecY /7;t7/77--46 / tv :JIFF/ ature of Auth : ed Person(specify title) Date EXHIBiT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 Wait Wftatike Ceii-V r NlrxiiVe W t,dtice SearviceS County of Hawai'i Nonprofit Grant Application FY202 1-22 Agency Name: Hawaii Wildlife Center Program Name: Native Wildlife Services 11. Certification of Understanding(Page 1 of 2) I (we)have read and understood all of the eligibility requirements;;grant conditions;award procedures;. and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135-2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I(we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment,property,or records pertinent to the grant,contract, or program for which funds were used. I (we)hereby certify that information supplied herein,including all supporting documents, is correct and that I(we) have the authority and ability to fully administer the program(s)pursuant to law. I (we)understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. ! (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, andthat we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we)'understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we)understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to htt.. vendors.ehawaii.:ov complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'!, i(we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,and accurate year-end report, using the template1nrovided, will. impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of;8 ail Wilai'gc eiNt tr t\tafi\+e u\iitclli-kc .envie--s County of Hawa. `i Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Wildlife Center Program Name: Native Wildlife Services 11. Certification of Understanding(Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. i (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at.1211cs ym rir-r o fit-gram(-iormsJ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead • costs.Any funds unused by June 30,2022 must be returned to the County of Hauvai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on privateproperties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ;.4 1<AZ":„.te" 006/20.2/ s 4 ature of Aut rized Person Date ?resr ii- 4 Ce villv b tree , Title/Position of Authorized Person EXHIBIT A NONPROFIT.GRANT APPLICATION FY 2021-2022 Page 7 of 8 } GlWaii W 1d1;Vie, Cen-Fer t4C41j ie VQ0CtI lte Se";c.Qs County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hawaii Wildlife Center Program Name: Native Wildlife Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant council Proposed Projected Results Projected Result Total native wildlife(bird and bat)patients provided rescue,medical treatment,and/or rehabilitation 400 Total public calls answered regarding wildlife issues and assistance with appropriate response 750 TABLE Ii: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages 6,500 Professional Fees Operations Supplies 2,500 Equipment Other: Wildlife Transport Other: Veterinary Services 1,000 Other; Wildlife Hospital internships Other: Wildlife Projects Other: Reference, Training TOTAL 10,000 Additional Council directives reeardinj award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hila Community Players 2021 Fall Musical 135 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hilo Comrriuhity Players Program Name:2021 Fall Musical Agency Director: Dr. Rachel Klein Phone N:o::(808 )959 -4588 Contact Person: Dr. Rachel Klein Phone No.:(808 )959 -4588 Mailing Address: Address: P.O. Box 46 Address: - City,ST,Zip. Hilo, HI 96721 Facility Address: Address:' Address: City,ST,Zip Email Address: HiloCommunityPlayers@Gmail.com Fax No.: ( ) - Accountant/CPA: Erin McClure (Treasurer) Phone No.:(808 ) 895 -0363 Firm (if applicable): Mailing Address: Address: P..O. Box 46 city,sr,zip Hilo, HI 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked; n Puna 0 Hamakua ri North Kona *South Hilo n North Kohala l South Kona n North Hilo n South Kohala ❑lca`u Services or Activities To Be Provided: (One or more cal be checked) n Educational concerns ©Youth ❑Victims of Crimes • Culture and the arts Aged I]Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021- 2022 Page 1 of 8 • County of Hawai`i Nonprofit Grant At-plication FTY72021-22 Agency Name: Hilo Community Players • Program Name: 2021 Fall Musical 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $4,800.00 N/A $3,250.00 • 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate,enrich,and inspire the Big Island community through quality theatrical productions,workshops,and activities for children,teens,and adults. ' • • • 3. Program Description: • The Hilo Community Players' annual-fall musical project always includes community members of ail ages.Past productions'have included "Next to Normal,""bare:a pop opera,""Shout!"and"Willy Wonka."These full-scale productions-offer varied opportunities for members of the community to learn theatrical and technical skills that can inspire young students and even translate to the workforce.Audience members are provided the opportunity to experience live theatre as well as an expansion of the,conversations around cultural activity to which they may not otherwise have access. In executing this program,we have in the past collaborated with the Palace Theatre and the East Hawaii Cultural Center with great success and intend to continue to do so. • • 4. Total Budget& Position Count: • Total Program Budget: $34,500.00 Total.Program Position Count: 80 Total Agency Budget: $1.20,000.00 Total Agency,Position Count:, 186 • • •EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of flawai`i Nonprofit Grant Application F 2021-22 Agency Name: Hilo Community Players • Program Name: 2021 Fall Musical 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source • Estimate Grant Support 13,500.00 Public Donations 8,000.00 Fundraising Events _ • 5,000.00 Existing Program Funds 8,000.00 1 _ TOTAL: 34,500 Attach additional pages,if needed. . 6. Explain what plans your agency or program has to increase revenues to support this program: For this program,the Hilo Community Players will host a supplemental fundraising event in addition to accepting • community donations through AmazonSmile,Facebook donations,and other charity tools.We are also launching a merchandise program with original designs and artwork. . • 7. Program Objectives Using County Nonprofit Grant Program Funds:' If awarded county nonprofit grant funding,the Hilo Community Players would be able to continue to produce artistic and educational live programming for communities on the Big Island.With grant funding,we will be able to offer free educational opportunities for children under 18. In addition,we intend to provide this rich program with ample performance opportunity and specialized training to members of the community of all ages.This program also provides ample volunteer work experience opportunities and the chance for volunteers to learn technical skills which could help them enter or develop their position in the workforce. By bringing our community together with the events of our program,we hope to enrich the lives of the people of the Big Island in a shared collaborative space. . • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name:2021 Fall Musical 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) z — Number of Public Audience Members Served 2,000 !Number of Performers Participating 55 I Number of Technical Skill Volunteers Participating 25 Number of Educational Workshops Offered 4 _ Public Attendance at Educational Workshops Offered 1100 —_ Number of Performances Provided to the_Community '9 Volunteer Hours Available 200 Par Volunteer Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual** j Total Budget Grant Req Salary and Wages 6,000.00 6,000.00 2,000.00 • Professional Fees 3,204.33 3,500.00 2,000.00 Operations • _ 1,767.84 3,000.00 1,500.00 Supplies 4,6e4.56 5,000.00 2,000.00 Equipment , 7,525.66 8,000.00 2,000.00 Other: Facility Rental • r 9,000.00 4,000.00 Other: Other: Other: Other: TOTAL 23,192.39 34,500.00_13,500.00 'If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-20.2.2 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hilo Community Players Program Name:2021 Fail Musical 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs tobe submitter. Please duplicate as needed to fully disclose. All disclosure forms must be signed, req; rdhss of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council 10 Staff appointed by a member of the Council • The Mayor Di The Managing Director O The Director of Finance II The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. ichdrteo il- 01115/2021 Si: ature s,� uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hilo Community Players Program Name:2021 Fall Musical is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting; and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used, I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authorityand ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timet com•lete and accurate ear-end resort usin• the tem slate •rovided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 - Page 6 of 8 County of Hawaii Nonprofit Grant Application 1,Y2021-22 Agency Name:Hilo Community Players Program Name:2021 Fall Musical 11. Certification of Understanding:(Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence)must be provided to the County of Hawai`i Finance Department,which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. . I (we) understand there is no provision for further notification to submit the final report. Information and:instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-formes on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. /� � ✓ f �__ 01 /15/201 Signature of A the, 'zed Person Date 1Cie Title/Position of Authorized Person EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2'021-22 Agency Name: Hilo Community Players Program Name:2021 Fall Musical AMEN 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Public Audience Members Served 2,000 Number of Performers Participating 55 Number of Technical Skill Volunteers Participating Number of Educational Workshops Offered 4 Public Attendance at Educational Workshops Offered 1100 Number of Performances Provided to the Community ;• 9 Volunteer Hours Available 1200 per volunteer TABLE II: • —� FY 21-22 Council PROGRAM EXPENDITURES G•r•2nt Request Award Salary and Wages 2,000.00 Professional Fees 2.,000.00 Operations 1500.00 Supplies — t: 2,000.00 Equipment —` — 2,000.00 Other: Facility Rental _ 4,0 0.00 Other: — --- ---.—_.— Other: -._—._._._.. Other: ---- - --- -I-- ----- - Other: -- — — --� — TOTAL 13,5.00.00 Additional Council directives regarding award: EXHIBIT B • NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hilo Community Players 44th Annual Shakespeare in the Park Festival 136 County of Hawai`i Nonprofit Grant Application' FY2021.-22 Agency Name:Hilo Community Players,) • • Program Name:44th Annual Shakespeare in the Park Festival Agency Director: Dr. Rachel Klein Phone No.:(808 ).'959 -4588 Contact Person: Dr. Rachel Klein Phone No.:(808 )959 -4588 Mailing Address: Address: P.O. Box 46 Address: City,sr,zip Hilo, HI 96721 Facility Address: Address: Address: City,ST,Zip Email Address: HiloCommunityPlayers@Gmail.com Fax No.: ( ) - Accountant/CPA: Erin McClure (Treasurer) Phone No.:(808 ) 895 —0363 Firm (if applicable): ' Mailing Address: Address: P.O. Box 46 City,ST,Zip Hilo, HI 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE.FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more a:an be checked) ® Puna ❑■ Hamakua ❑ North Kona l®l South Hilo ❑ North Kohaia ❑South Kona ® North Hilo ❑South Kohala [J Ka`u Services or Activities To Be Provided: (One or r,ore can be checked) ■ Educational concerns ■❑Youth ❑Victims of Crimes n Culture and the arts 0 Aged ❑Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A V NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application. FY2021-22 Agency Name: Hilo Community Players • Program Name: 44th Annual Shakespeare in the Park Festival • 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20--21 $4,800 N/A $3,450 • 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate, enrich,and inspire the Big Island communF:y through quality theatrical productions,workshops,and activities for children,teens,and adults. • • • • • • 3. Program Description: • The 44th Annual Shakespeare in the Park Festival program usually presented in Kalakaua Park,and includes opportunities for children,teens,and adults of all ages to participate in the production process of one full-length Shakespeare play.The 2020-2021 season's innovative drive-in production of"Othello"became the most-attended Shakespeare in the Park production yet. Our Summer 2021 production will be"Romeo and Juliet"a classic Shakespearean favorite that we expect will draw island-wide talent in addition to appealing to our largest,most diverse audiences. Due to the interest in the title,we also expect that the eduational workshop components of the program will be well attended and well received by the community. • 4.Total Budget& Position Count: Total Program Budget: 1-I$ 24,200.00 Total Program Position Count: 75 •Total Agency Budget: 1$120,000.00 Total Agency,Position Count: 186 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name: 44th Annual Shakespeare in the Park Festival • 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source . Estimate Grant Support 10,500.00 Public Donations — 4,000.00 I Fundraising Events 2,700.00 }Existing Program Funds 7,000.00 • TOTAL: 1 4,200.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As Shakespeare in the Park is funded entirely by community donations,fundraising efforts,and grants,we offer free • admission.We intend to make use of community outreach, partnering with teachers,students, and local businesses. "Romeo and Juliet"boasts excellent name recognition with audiences far beyond the usual theatre-goers, in turn benefiting wider participation and greater fundraising opportunities. • 7. Program Objectives Using County Nonprofit Grant Program Funds: If awarded county nonprofit grant funding,the Hilo Community Players would be able to continue to produce artistic and' educational live programming for communities on the Big Island.With grant funding,we will be able to offer free educational opportunities for children under 18,an especially valuable experience during the summer months when school is not in session. In addition,we intend to provide this rich program with ample performance opportunity and specialized training to members of the community of all ages.This program also provides ample volunteer work experience • opportunities and the chance for volunteers to learn technical skills which could help them enter or develop their position in the workforce.By bringing our community together with the events of our program,we hope to enrich the lives of the people of the Big Island in a shared collaborative space. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name:44th Annual Shakespeare in the Park Festival 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) I Number of Public Audience Members Served 1500 ;Number of Performers Participating • 60 Number of Technical Skill Volunteers Participating 15 I Number of Educational Workshops Offered 2 I Public Attendance at Educational Workshops Offered 50 Number of Performances Provided to the Community 'i 1 Volunteer Hours Available ,' 1200 Per Volunteer Attach additional pages as necessary. • 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 2,150.00 4,000.00 2,000.00 Professional Fees 2,098.00 2,100.00 1,000.00 Operations . 2,536.48 3,500.00 1,500.00 Supplies 3,776.76 16,000.00 2,500.00 Equipment _11,084.64 i_5,000.00 2,500.00 Other: Equipment Storage 3,000.00 3,600.00 1,000.00 Other: Other: - - -- I Other: Other: TOTAL 24,645.88 124,200.00 10,500.00 *If applicable • • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application 7)(2021-22 Agency Name:Hilo Community Players Program Name:44th Annual Shakespeare in the Park Festival. ,� 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Flawai`i. Only those listed below need to be disclosed.'One form per person with a conflict is needed. If no.conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): [l Member or members of the Council . • Staff appointed by a member of the Council ® The Mayor f The Managing Director I] The Director of Finance • The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that actiontaken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an.industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest:. RI If no conflicts exist, check here. 01 /15/2021 :, Sign.ture of th ed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2(;21 2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application it' 2021-22' Agency Name:Hilo Community Players Program Name:44th Annual Shakespeare in.the Park Festival 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code,relating to Appropriation of Fundsto Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted accsss and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have lull responsibility to ensure that all documents are complete and accurate prior to submittal. i (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents.v✓ill be disqualified. Faxed er copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of they grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accuratevear-end report, using the tem plate_provided, will impact the evaluation of your procrxm's or agency's future lundinp rtauests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021•-2022 Page 6 of 8 • County of Hawai`i Nonprofit Grant Appiicatioti. . F` 2021-22 Agency Name:Hilo Community Players Program Name:44th Annual Shakespeare in the Park Festival 11. Certification of Understanding (Paged of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written resort is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except fora maximum ten percent (10%)icor administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. / 01/15/201 - Si lutherized Person Date Aden+ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 • Agency Name: Hilo Community Players Program Name:44th Annual Shakespeare in the Park Festival 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1 Number of Public Audience Members Served 1500 Number of Performers Participating . 60 Number of Technical Skill Volunteers Participating 15 j Number of Educational Workshops Offered 2 1Public Attendance at Educational Workshops Offered 50 (Number of Performances Provided to the Community 11 Volunteer Hours Available �00 per volunteer • TABLE II: -- — FY Z1-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 2,000.00 Professional Fees 1,000.00 Operations 1,500.00 Supplies 2,500_00 Equipment 2,500.00 _ Other: Equipment Storage 1,000.00 Other: Other: -- — — — Other: Other: — TOTAL 110,500.00 Additional Council directives regarding award: • • EXHIBIT B • NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HiUo Community Players Kid-Shakes Presents 137 • County of Hawai`i Nonprofit Grant Application . .Y2021-22 Agency Name:Hilo Community Players Program Name:Kid-Shakes.Presents ..Wu Agency Director: Dr. Rachel Klein Phone No.:(808 )959 —4588 • Contact Person: Dr. Rachel Klein Phone No.:(808 )959 —4588 Mailing Address: Address: P.O. Box 46 Address: • City,ST,zip Hilo, HI 96721 Facility Address: Address: Address: City,ST,Zip Email Address: HiloCommunityPlayers@Gmail.com Fax No.: ( ) — Accountant/CPA: Erin McClure (Treasurer) Phone hone No.:(g ;?), ) 395 —0363 Firm (if applicable): Mailing Address: Address: P.O. Box 46 City,ST,Zip Hilo, HI 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT ANIS COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ra Puna ®] Hamakua ❑ North Kona [121 South Hilo ❑ North KohalaaI L_,South Kona n North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more a carp be checked) ® Educational concerns {ii Youth ri Victims of Crimes Culture and the arts Lj Aged n Victims of Health or Social Crises • Needs of the poor ❑Physical/Emotional Disabilities • Public Health and Welfare of the People and they Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 _J County of-Hawai`i Nonprofit Grant. Applic-at: on F Y2021-22' Agency Name: Hilo Community Players. Program Name: Kid-Shakes Presents • 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A N/A 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate,enrich,and inspire the Big Island community through quality theatrical productions,workshops,and activities for children,teens,and adults. 3. Program Description: Kid-Shakes is an annual program our agency began 7 years ago to make the literature of Shakespeare more accessible to keiki. Kid-Shakes is a program in which an original adaptationa Shakespeare play designed to educate and entertain young audiences.The program offers our younger community members the opportunity to participate.in every aspect of mounting a production,and is an excellent way to introduce them to Shakespeare's'rich literary world in an appropriate, accessible family-friendly format.The scripts are designed to appeal to young audiences and to begin to introduce the complex topics tackled by the writing of Shakespeare.This year we plan to expand the program,doubling the number of staff and volunteers and therefore the number of keiki that can actively take part-in and learn the production process. 4.Total Budget& Position Count: Total Program Budget: I$ 7,400.00 Total Program Position Count: 125 Total Agency Budget: 1$120,000.00 1 Total Agency Position Count:j 186 EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • • County of Hawai i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name: Kid-Shakes Presents 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate • Grant Support � 4,000.00 Public Donations 2,000.00 Fundraising Events 1,400.00 TOTAL: 7,400.00 • Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As Kid-shakes is funded entirely by community donations,fundraising efforts, and this year we hope by grant funds.This program always offers free admission to the general public,as a way of keeping it accessible to families with multiple children or!ewer incomes.As such,we rely on the aforementioned sources to fun the program.Ws advertise this program specifically each year and encourage program specific donations from our benefactors. • 7. Program Objectives Using County Nonprofit Grant Program Funds: If awarded county nonprofit grant funding,the Hilo Community Players would be able to continue to produce artistic and educational live programming for younger members of the Big Island community.With grant funding we are able to offer free educational opportunities for children---an especially valuable experience during the summer months when school is not in session. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name: Kid-Shakes Presents 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of Public Audience Members Served ®! 500 Number of Performers Participating • 20 Number of Technical Skill Volunteers Participating 5 Number of Educational Workshops Offered 1 Public Attendance at Educational Workshops Offered 25 Number of Performances Provided to the Community 8 Volunteer Hours Available 150 Per Volunteer Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 800.00 _2,000.00 1,000.00 Professional Fees _^800.00 800.00 Operations _ 2,128.84 _ 3,000.00 1,500.00 Supplies _ 774.35 H 1,000.00 500.00 Equipment 450.00 600.00 200.00 Other: --" Other: Other: - Other: _— • Other: TOTAL_4,153.19 7,400.00 4,000.00 *If applicak:da • • • EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of flawai`i Nonprofit Grant Application FTY2021-22 Agency Name: Hilo Community Players Program Name:Kid-Shakes Presents 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose,any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless a vyj ether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ® Member or members of the Council [� Staff appointed by a member of the Council ® The Mayor The Managing Director In The Director of Finance Q The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 01/15/2021 Ffeliactoryt- Sig ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 202.1-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application 1 "Y2021-22 Agency Name:Hilo Community Players Program Name:Kid-Shakes"Presents 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting; and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code,.relating to.Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnelreceiving our County Nonprofit Grant submittal, and.that we have e full responsibility to ensure that all documents are complete and accurate priorto submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the,County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit Card. • If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after'June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding ofthe grant(focusing onspecific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's-future funding requests: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021!'=2022 Page 6 of 8 County of Hawai`i. Nonprofit Grant App cation ' FY2021-22 Agency Name:Hilo Community Players Program Name:Kid-Shakes Presents 11. Certification of Understanding (Page'2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a;current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received durinthe-grant period (must be refunded to Conant and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit::grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover thesgiunds. Awards cannot provide funds for Capita! Improvements(Cost of Construction, rnz,t��:rials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01115/201 Signa ure of Aut orized Person Date f21'*- din Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application ' FY2021-22 Agency Name: Hilo.Community Players • Program Name: Kid-Shakes'Presents 12. COUNCIL AWARD WORKSHEET TABLE I: • . PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Public Audience Members Served . 500 Number of Performers Participating 20 Number of Technical Skill Volunteers Participating 5 Number of Educational Workshops Offered 1 Public Attendance at Educational Workshops Offered• Number of Performances Provided to the Community 8 Volunteer Hours Available 150 per volunteer TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages 1,000.00 Professional Fees _ 800,00 • Operations I 1,500.00 Supplies 500,00 Equipment _ 200.00 • Other: Other: - --- — -_—.-- - Other: Other: • Other: _ — TOTAL."4,000_00 Additional Council directives regarding award: • • • • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 • Page 8 of 8 Hilo Community Players LGBTQIA+ Outreach 138 County of Hawaii Nonprofit Grant Application ' FY2021-22 Agency Name:Hilo Community Players Program Name:LGBTQIA+ Outreach Agency Director: Dr. Rachel Klein Phone No.:(808 )959 —4588 Contact Person: Dr. Rachel Klein Phone No.:(808 )959 —4588 Mailing Address: Address: P.O. Box 46 Address: City,ST,Zip Hilo, HI 96721 Facility Address: Address: Address: City,ST,Zip Email Address: HiloCommunityPlayers@Gmaii.com Fax No.: ( ) — Accountant/CPA: Erin McClure (Treasurer) Phone No.:(808 ) 895 —0363 Firm (if applicable): Mailing Address: Address:. P.O. Box 46 City,ST,Zip Hilo, HI 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) * Puna Hamakua North Kona ®i South Hilo ❑ North Kohala' L South Kona ® North Hilo 0 South,Kohala LJ Ka'o Services or Activities To Be Provided: (One or more can be checked) • Educational concerns ®❑Youth L4 Victims of Crimes n Culture and the arts rill Aged • LJ Victims of Health or Social Crises 7 Needs of the poor . I-1 Physical/Emotionl Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application F'Y 2=.121-22 Agency Name: Hilo Community Players . Program Name: LGBTQIA+ Outreach assnissarszassumrammaffisi 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A N/A 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate, enrich,and inspire the Big Island community through quality theatrical productions,workshops,and activities for children,teens,and adults.' 3. Program Description: The theatre world has long been a safe place for those questioning or exploring their sexuality or gender. Hilo Community Players will build on this tradition,providing space for teens and adults to safely explore LGBTQIA themes in theatrical writings and;to learn from each otherin the,supportive, positive environment that performing arts encourages.With this new program;we hope to collaborate with Big Island Pride and other local groups to provide the education and access for participants. 4. Total Budget& Position Count: Total Program Budget: '$ 7,600.00 Total Program Position Count: 50 Total Agency Budget: $120,000.00 Total Agency Position Count: 186 -EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 - Page 2 of 8 County of Hawai`i Nonprofit Grant Application li Y2021-22 Agency Name: Hilo Community Players Program Name: LGBTQIA+ Outreach 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Grant Support 5,100.00 Community Donations • _ 1,500.00 Fundraising Events 1,000.00 TOTAL 7,600.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hilo Community Players will host a fundraising event in addition.to accepting community donations through AmazonSmile, Facebook donations,and other charity tools.We are also launching a merchandise program with original designs and artwork that will help to support this program. • 7. Program Objectives Using County Nonprofit Grant Program Funds: With the improved resources of the county nonprofit grant program, HCP hopes to provide a safe, reassuring,and positive environment for teens and adults to r dceive the community and support they may desperately need.Additionally, in presenting works with LGBTQIA+themes to the larger Big Island community, unfamiliar audiences are able to experience these cultural conversations from a place of understanding and compassion. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application F'Y2021-22 Agency Name: Hilo Community Players Program Name: LGBTQIA+ Outreach 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of Perofrmers Participating _ 40 Number of Technical Skill Volunteers 10 Participant Before and After Self Acceptance Questionnaire _ 10 point imp ovement average Number of Community Performances 9 Number of Public Audience Members Served/Educated 1,000 Number of Educational Workshop Attendees 50 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 7 3,000.00 2,000.00 Professional Fees • Operations 2,000.00 1,500.00 Supplies 1,000.00 500.00 Equipment 1,000.00 500.00 Other: Faciliity Rental 600.00 600.00 Other: Other: Other: Other: TOTAL 7,600.00 5;100.00 *if applicable • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit-Grant Application FY2021-22 Agency Name:Hilo Community Players Program Name: LGBTQIA+ Outreach • 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of.Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regard3ess of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): El Member or members of the Council • Staff appointed by a member of the Council, ® The Mayor In The Managing Director • O The Director of Finance f The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will resulr in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. • >! � 01%1 x/2021 . Signature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit ''rant Application FY2021-22 Agency Name: Hilo Community Players Program Name:LGBTQIA+ Outreach 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand thatapplications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that rail documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document.,Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step prdcess.'and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supposed by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report`usinq the template provided, will impact the evaluation of your program's or acLency's future funding requests. EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2023.-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 i Agency Name:Hilo Community Players Program Name:LGBTQIA+ Outreach 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we') understand thata current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,youacknowledge that any funds awarded will be restricted for the purposes stated in the,.application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned,to the County of Hawari with the final report. Failure to return these funds in a timely manner will impact the Evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • /'! a, 1 /1x/201 Sig or of .'ho -Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Appl. .cation. FY2021-22 Agency Name: Hilo Community Players Program Name:LGBTQIA+ Outreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Perfromers Participating 40 Number of Technical Skill Volunteers 10 Participant Before and After Self-Acceptance Questionnaire ho pt avg improvement Number of Community Performances g Number of Public Audience Members Served/Educated jl,OOO Number of Educational Workshop Attendees 50 TABLE II: PROGRAM EXPENDITURES T- FY 2 .-22 Council Grant Request Award Salary and Wages 2,0.00.00 ProfessionaiFees Operations 1.:00..00 Supplies 500.00 Equipment - 500.00 Other: Facility Rental _ 600.00 Other: Other: • - Other: -__ ------- --- Other: — - - -t - - - -_ TOTAL 5100.00 Additional Council directives regarding award: • • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hilo !Community Players Na Mea Hawaii Theatre 139 County of'Hawai`i Nonprofit Grant Application I FY2021-22 Agency Name:Hilo Community Players Program Name:Na Mea H<awai'i Theatre u r , NUM Agency Director: Dr. Rachel Klein Phone No.:(808 )959 -4588 Contact Person: Dr. Rachel Klein Phone No.:(808 )959 —4588 Mailing Address: Address: P.O. Box 46 Address: City,ST,Zip Hilo, HI 96721 • Facility Address: Address: Address: City,ST,Zip Email Address: HiloCommunityPlayers©Gmai!.com Fax No.: ( ) - Accountant/CPA: Erin McClure (Treasurer) Phone No::(808 ) 895 -0363 Firm (if applicable): Mailing Address: Address: P.O. Box 46 City,ST,Zip Hilo, HI 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can he checked) 11:11 Puna [] Hamakua ❑ North Kona *I South Hilo ❑ North Kohala ❑South Kona is North Hilo I _1 South,Kohaia ❑ Ka`.0 Services or Activities To Be Provided: (One or more can be checked) ® Educational concerns Youth ❑Victims of Crimes la Culture and the arts Aged (Y;Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and theEnvironment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name: Na Mea Hawaii' Theatre 1. Prior Year Award of County Nonprofit Grant Program Funds:. FY 18-19 FY 19-20 FY 20-21 N/A N/A $3,800.00 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate,enrich,and inspire the.Big,Island community through quality theatrical productions,workshops,and activities for children,teens,and adults. 3. Program Description: The Hilo Community Players are committed to producing a play each season that comes from the Pacific Islands.We cultivate local.playwrights and often search out new local plays that explore life in Hawaii.This program has produced historical plays.that help perpetuate Native Hawaiian culture and history,as well as productions about modem-day local culture and'pidgin'adaptations of famous works,which help make the performing arts accessible to a broad range of people in our Hawaii community.The goal of this program is to increase awareness of local art,topics and artists and to specifically focus on those artists and playwrights here in our islands. 4. Total Budget& Position Count: Total Program Budget: $24,500.00 Total Program Position Count: 40 Total Agency Budget: $120,000.00 . . Total Agency Position Count: 186 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 ' Agency Name: Hilo Community Players • Program Name: Na Mea Hawai'i Theatre WINEMEIMINIMMVIVIPM 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Grant Support 11,000.00 Public Donations • 4,000.00 Fundraising Events 4,000.00 Existing Program Funds 5,500.00 TOTAL: 24,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hilo Community Players will host at least one supplemental fundraising event in addition to accepting community donations through AmazonSmile, Facebook donations,and other charity tools.We are also launching a merchandise program with original designs and artwork to help support this program. • • 7. Program Objectives Using CountyNonprofit Grant Program Funds: If awarded county nonprofit grant funding,the Hilo Community Players will be able to continue to present locally-written and Hawaiian-themed productions as part of this program.The funding would greatly subsidize the cost to participants, allowing for further outreach in the Big Island community.The cost of this program in the 20-21 FY ware kept low due to the generous donation of work form the playwright and virtual formatting due to the.ongoing pandemic,but we expect higher expenses next year as we have had in the past for this program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of flawai`i Nonprofit Grant Atp1ic atior: F12021-22 Agency Name: Hilo Community Players Program Name: Na Mea Hawai'i Theatre 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? • PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of Public Audience Members Served _ 2,000 Number of Performers Participating 30 Number of Technical Skill Volunteers Participating 10 _ Number of Educational Workshops Offered 2 j Public Attendance at Educational Workshops Offered 50 Number of Performances Provided to the Community 9 Volunteer Hours Available JOo Per Voli,nteer Attach additional pages as necessary. 9.TABLE II: . FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages • 2,000.00 2,000.00 5,000.00 2,000.00 Professional Fees 1,500.00 500.00 Operations 1,133.79 3,000.00 1,500.00 Supplies 4,.694.56 4,000.00 2,000.00 Equipment • 3,153.24 2,000.00 1,000.00 Other: Facility Rental 9,000.00 4,000.00 Other: Other: Other: • --- 1 Other: TOTAL 10,981.59i 24,500.00 11,000.00 *If applicable • • • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name:Na Mea Hawai'i Theatre 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless oLwhether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): [I Member or members of the Council Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance II.:-; The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. ti - 01`/1 .x/2021 rirecSignature of ut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021—2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Applioat.ic,'n FY2021-22 Agency Name: Hilo Community Players Program Name:Na Mea Hawai'i Theatre 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. i (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used.. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai`i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step roce:s,'and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and Will comfy with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a compiwte accounting of all expenditures supported byCounty of Hawaii . _ . grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete! and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests, EXHIBIT A NONPROFIT GRANT APPLICATION FY 202.1-2022 Page 6 of 8 ' County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Hilo Community Players Program Name:Na Mea Hawai'i Theatre 11. Certification of Understanding (page-2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000,each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June,30th shall result in loss of all grant funds,received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:/Jwww.hawaiicountv.gov/fn-nonprofit-grant-farms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the,application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)'on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have.read°and-'understood these-requirements. 01 /15/201 Sig ature oft 'thorized Person Date t,6lder t Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name:Na Mea Hawai'i Theatre 12. COUNCIL AWARD WORKSHEET • TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of Public Audience Members Served 2,000 _ Number of Performers Participating 30 Number of Technical Skill Volunteers Participating 10 Number of Educational Workshops Offered 2 Public Attendance at Educational Workshops Offered • 50 Number of Performances Provided to the Community 9 Volunteer Hours Available . 200 per volunteer TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 2,000.00 Professional Fees 500.00 Operations 1,500.00 _ Supplies 2,000.00 Equipment 1,000.00 Other: Facility Rental 4,000.00 Other: Other: _ Other: • Other: TOTAL 1-11,0c0.00 Additional Council directives regarding award: • • • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HiloCommunity Players Rising Stars 140 County of Hawaii Nonprofit Grant Applicatio>? F Y 2 021-22 Agency Name:Hilo Community Players Program Name:Rising Stars Agency Director: Dr. Rachel Klein Phone No.:(808 )959 -4588 Contact Person: Dr. Rachel Klein Phone No.:(808 ).959 —4588 Mailing Address: Address: P.O. Box 46 Address: City,ST,Zip Hilo, HI 96721 Facility Address: Address: Address: City,ST,Zip Email Address: HiloCommunityPlayers@Gmail.com Fax No.: ( ) - Accountant/CPA: Erin McClure (Treasurer) Phone No.:(808 ) 895 —0363 Firm (if applicable): Mailing Address: Address: P:O. Box 46 City,ST,Zip Hilo, HI 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND.COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) • Puna C Hamakua El North Kona 0 South Hilo 0 North Kohala L]South Kona O North Hilo ❑South Kohala ❑ Ka`u: Services or Activities To Be Provided: (One or more can be checked) O Educational concerns El Youth ❑Victims of Crimes n Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment _. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant A-pplication F Y2021-22 Agency Name: Hilo Community Players Program Name: Rising Stars 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A N/A 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate,enrich.and inspire the Big island community through quality theatrical productions,workshops,and activities for childref,teens,and adults. • 3. Program Description: This musical-theatre camp is has summertime annual tradition for young thespians.The Hilo Community Players have collaborated with Taylor Made Music, Devon Marie Piano Studio, Paradise Performing Arts Center, Clean Heart Art,the East Hawai'i.•.Cultural Center and other local talent for a comprehensive course in the theatrical arts. Part cipants from 7-15 years old study drama, music,dance, and technical theatre-;,displaying newfound skills in a final showcase performance. This year we intend to expand the program to consist of'course.s in the Fall and Spring as well,so that our talened young rising stars may learn performance and stage skills year round.We will also be beginning an arts in the schools arm to this program, bringing some of the available classes directly to Big Island school,. 4.Total Budget& Position Count: Total Program Budget: $ 16,800.00 Total Program Position Count: 15 Total Agency Budge:; $120 000.00 Total Agency Position Count: 186 . EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 cif 8 • • County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name: Rising Stars • • 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Grant Support 8,300.00 • Tuition 6,000.00 Fundraising Events 500.00 Existing Program Funds • _ 2,000.00 TOTAL: 16,800.00 • Attach additional pages,if needed. -- 6. Explain what plans your agency or program has to increase revenues to support this program: To supplement and subsidize the tution for this program, Hilo Community Players will host at least one fundraising event in addition to accepting community donations through AmazonSmile, Facebook donations,and other charity tools.We are. also launching a merchandise program with original designs and artwork which will help to support this program. • • 7. Program Objectives Using County Nonprofit Grant Program Funds: If awarded county nonprofit grant funding,the Hilo Community Players would be able to subsidize tuition costs for students and provide grants to those in need of financial assistance. In addition the grant funding would cover bringing the classes into island schools.This program is an excellent educational opportunity for keiki and teens and in the past has been especially valuable experience during the summer months when school is not in session.The 20-21 FY actual costs were very low because we did a very minimized version of this program,with a greatly reduced number of classes offtered virtually in the summer months, but this year,we expect to return the program to.its full operation and expand into a year round program. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application F Y2021-22 Agency Name: Hilo Community Players • Program Name: Rising Stars • 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? • PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your • program?Describe,be specific.) Number of Students Served 200 Number of Classes Offered 120 Number of Children's Performances 6 Parent/Student Satisfaction with the program 9-10/10(to be surveyed) School Satisfaction with the program 2-10/10(to be surveyed) Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 I FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,000.00 10,000.00 6,000.00 Professional Fees t Operations 581.13 3,000.00 1,500.00 Supplies 435.11 2,000.00 500.00 Equipment 400.00 800.00 Other: Faciliity Rental _ 1,000.00 300.00 Other: Other: Other: -1 Other: TOTAL _2,416.24 j 16,800.00 8,300.00 *If applicable • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of FIawai`i :Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name:Rising Stars 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Fiawai'l. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council O Staff appointed by a member of the Council ® The Mayor DI The Managing Director 7 The Director of Finance • The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruingin general to an industry. • Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. er 01/15/2021 Sig ature of ut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021:2022 Page 5 of 8 County of Hawai'i Nonprofit Grant Application, FY20'21-22 Agency Name: Hilo Community Players Program Name: Rising Stars 11. Certification of Understanding (Page 1 of 2). I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we)'understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hilo Community Players Program Name:Rising Stars 11. Certification.of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we.) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and• accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn=nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the;application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the;evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized bylaw. By signing below,you are acknowledging that you have read and understood these requirements. 01 /15/201 Signature o uthorized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2027,-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hilo Community Players Program Name:Rising Stars 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Students Served 200 Number of Classes Offered 120 Number of Children's Performances 6 Parent/Student Satisfaction with the program _ 9-10/10 School Satisfaction with the program 9-10/10 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 6,000.00 Professional Fees Operations' 1,500 00 Supplies 500.00 Equipment 300.00 Other: Other: 1 Other: Other: Other: TOTAL L8,300.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION F _ .Y 2020 2021 Page 8of8 Ho'ulu Lahui Planning for a Community Agriculture-Based Resilience Hub in Puna 142 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'oulu Lahui Program Name:Planning for a community agriculture-based resilience hub in Puna Agency Director: Luika Imaoka Phone No.:(80++) 987 —6950 Contact Person: Susie Osborne Phone No.:(808)640 —3439 Mailing Address: Address: 345 Makalika Street Address: City,ST,Zip Hilo, HI. 96720 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: Susie@kuaokala.org Fax No.: (808 ) 933 —0803 Accountant/CPA: Jannette Pelton Phone No.:(808) 769 —3872 Firm (if applicable): Mailing Address: Address: 345 Makalika Street City,ST,Zip Hilo, HI. 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for.County Nonprofit Grant Program Funds: 47,250.00 _ ., _ur• .a,— _ '�xI Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona D South Hilo 0 North Kohala ❑South Kona ❑North Hilo ❑South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) E Educational concerns Q Youth ❑Victims of Crimes Q Culture and the arts ❑Aged ❑Victims of Health or Social Crises O Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ho'oulu Lahui Program Name: Planning for a community agriculture-based resilience hub in Puna 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 2,000.00` 3,860.00 500,000.00 2.Agency Mission Statement: Ho'oulu Lahui is a 501(c)3 formed in 1995 with themission of awakening Hawaiian culture,values,beliefs and lifestyle in partnership with the community to achieve unity, harmony&total well-being. It's numerous goals&accomplishments include being the primary support entity for Kua 0 Ka La Charter School(KOKL)including facilities&being a fiscal sponsor for grants.Our community education center&school facility was consumed by the 2018 Kilauea eruption. The non-profit&the school have historically focused on at-risk Native Hawaiian students&families.As public entities,we welcome all to join our programs.We offer diverse programs that serve all ages from keiki to kupuna. KOKLhas a pre-K site in Nanawale,down the road from this proposed project site development and is clearly one stakeholder group of interest for this project.We have partnered with dozens of organizations locally including but not limited to: public and private schools(K.S.),O.H.A. BISAC,also Statewide,National and International collaborations.Our program components include sustainable economic&environmental development initiatives,being an experiential education site, a place for cultural practitioners,employment&training,a site for mental, physical and spiritual health,a safe place for families to come for rejuvenation. 3. Program Description: Ho'oulu Lahui,the 501 c3 supporting Kua 0 Ka La Charter lost its 600 acre site from the Kilauea eruption.The non-profit, Malama 0 Puna donated 10 acres of raw land in Nanawale (see county records and valued at$52,900.00)to Ho'oulu Lahui to support the project based needs of the school and the community with a vision of supporting an agriculture focused resilience hub in addressing food security, including production and distribution of food,native plants,farm to table,cultural, place and project based activities.A strategic plan with conceptual site drawings is the first step to the development of this property for community use.Our initial vision of the site plan includes roads,greenhouses,pili hale, imu, meeting rooms, hale wa'a, A planner will be contracted for the design process to include: Phase 1 -conduct immersive research with stakeholders,individual and organizations will engage in interviews and workshops to identify the priorities of the project and AGtahlish a detailed program for the future community resilience hub Phase 2-Production of a Site Plan and Conceptual Drawings illustratii,y upiortunities and challenges,how the site can be developed,and a concept design for the future hub.b.These articulate the leadership's vision of the Community Resilience Hub which can be used to deliverables will support capital fundraising efforts to finance the project.A project budget for this development will also be developed in addressing next steps,funds required, and other resources needed. 4. Total Budget& Position Count: Total Program Budget: 101,150.00 Total Program Position Count: 1 Total Agency Budget: 164,172.00 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 Countyof Hawai'i 6' way 1 Nonprofit Grant Application FY2021-22 Agency Name: Ho'oulu Lahui _ Program Name: Planning for a community agriculture-based resilience hub in Puna 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Donation of 10 acres of land by Malama 0 Puna 52,900.00 Grant request 47,250.00 TOTAL: 101,150.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will seek other grant funding for the site development- We believe the project will be able to self sustain itself upon development of the site for community use. Community partnerships and Collaborations:The organization will partner with entities such as KUPU for securing Interns for the site development and program operations. Ho'oulu Lahui is in the process of applying to become an Ameri Corp partner so that we can provide job training and other training initiatives. 7. Program Objectives Using County Nonprofit Grant Program Funds: Phase I:Site Analysis(Physical,Genealogical,and Cultural Context) Mo'oku'auhau of the place(site visit and site analysis,connecting the genealogy 4f the place to the present and into the future) Understanding and Addressing Community Needs(Social and Economic Context) Mo'olelo of the community stakeholders,connecting them to the place(meeting with community stakeholders) Phase II: Community engagement Huaka'i(participatory workshops with community stakeholders&individual interviews) 'Ike Honua—Learning from the land,site analysis to improve reciprocal relationships between the design and the land. Phase III:Design Development:Completed site plan renderings Waiwai(shared values—designing together -integrated design process) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ho'oulu Lahui Program Name: Planning for a community agriculture-based resilience hub in Puna 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Site analysis Focus groups with Community stakeholders+Interviews Report of site analysis by contractor Design site plan renderings 10 hours documented focus groups/interviews Completed site plan Attach additional pages as necessary. 9.TABLE H: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Reg Salary and Wages Professional Fees `x,000.00 7,000.00 Operations 3g,240.00 3 ,240.00 Supplies - —- Equipment 2,040C-& Other: In Kind land donation Other: 52,900.00. Other: Other: Other: TOTAL 101,150.00 45,240.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 2022 Page 4 of 8 County of Hawai6i Nonprofit Grant Application FY2021-22 Agency Name: Flo'oulu Lahui Program Name: Planning for a community agriculture-based resilience hub in Puna 100 ORGANIZATION CONFLICT DISCLOSURE FOR -� Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Luika lmaoka POSITION: President, Board of Directors May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council • The Mayor O The Managing Director 0 The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: j If no conflicts exist, check here. January 27,2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: HO'oulu Lahui Program Name: Planning for a community agriculture-based resilience hub in Puna EINIMMEMswzapagnagarallialli 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ho'oulu Lahui Program Name: Planning for a community agriculture-based resilience hub in Puna �. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. J, nuary 27, 2021 Signature of Authorized Person Date President Board of Directors Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Ho oulu Lahui Inc. Program Name: Planning for a community agriculture-based resilience hub in Puna 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Site analysis by contracted planner Report of site analysis by contractor Focus groups with Community stakeholders + Individual Interviews Design site plan renderings Completed site plan TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages -000.00 Professional Fees 38,240.00 Operations Supplies 2,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 47,240.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Holualoa Village 'Ghana Coffee &Art Stroll 143 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Holualoa Village Ohana Program Name:Coffee &Art Stroll Agency Director: Jaelyn Rockman Phone No.:(808 ) 640 -4094 Contact Person: Clare WilsonPhone No.:(805) 322 —7094 Mailing Address: Address: Post Office Box 100 Address: City,ST,zip Holualoa, HI 96725 Facility Address: Address: Address: City,ST,Zip Email Address: clarewilson98@gmail.com Fax No.: (808 ) 322 —7094 Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 6,000 Geographical Areas To Be Served: (One or more-can be checked) ❑ Puna ❑ Hamakua 0 North Kona ❑South Hilo 0 North Kohala 0 South Kona ❑ North Hilo 0 South Kohala ❑ Kell Services or Activities To Be Provided: (One or more can be checked) EI Educational concerns 0 Youth ❑Victims of Crimes Culture and the arts ❑Aged ❑Victims of Health or Social Crises Cl Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Coffee &Art Stroll 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 3410. 2.Agency Mission Statement: The mission of the Holualoa Village Ohana is to preserve the historical importance of Holualoa and the village heritage as well as provide opportunities to promote the area's coffee growing heritage,artistic assets,and cultural traditions through the organization of educational community events 3. Program Description: As the center of North Kona coffee production,each year in November,Holualoa Village kicks off the Kona Coffee Cultural Festival(KCCF)with the Coffee&art Stroll.The Stroll is paramount in highlighting the pivotal ole that coffee farmers have played in Kona's rich history as well as the role they continue to have in Kona coffee's future. Approximately 30 coffee farms will set up booths where they give out tasting samples of their homegrown Kona coffee and offer the coffee and other local farm products for sale.This event brings the community together with the large influx of people visiting Kona for the KCCF and provides an opportunity for farmers to educate the public about Kona coffee and coffee production as part of the rich heritage of Kona and Holualoa. In addition,there is some economic opportunity for participating farmers as they sell their coffee and perhaps pick up some long time customers. Every attendee has a chance to participate by voting for their favorite coffee in the People's Choice award,and three Big Island Chefs sample each farmer's coffee to select the winner of the Chefs Choice award.These awards recognizes the excellence in the craft of the coffee farmers. All the Holualoa art galleries are open and several artisans highlight the occasion with coffee themed arts and crafts.The Holualoa Elementary School sets up a coffee-based art exhibit by the students in the old Holualoa library. Educational/informational booths are also set up for the event.The Coffee&Art Stroll is an event that celebrates all that Holualoa Village has to offer a rich coffee background,talented artists,and historically significant buildings. 4.Total Budget&Position Count: Total Program Budget: 7000 Total Program Position Count: Total Agency Budget: 1 0000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Coffee & art Stroll 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Sponsors 1,0.00 Logo item sales 500 Food Vendor donations 700 TOTAL: 2,200 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Identify more sponsors Expand logo items 7. Program Objectives Using County Nonprofit Grant Program Funds: Educating the attendees about Kona coffee-its excellence and its challenges. Informing the attendees of the historical significance of Holualoa Village and the surrounding agricultural region. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Coffee &Art.Stroll 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) — Number of participating farmers Number of other educational displays The many postive responses we get, and the lack of negative c Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees 5000 5000 Operations Supplies 2000. 1100 Equipment 500 500 Other: Event insurance 650 0 Other: Permit 100 0 Other: Logo items 600 400 Other: Other: TOTAL 8850 7000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Holualoa Village Ohana Program Name:Coffee & Art Stroll 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council O The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: gIf no conflicts exist, check here. ' • , .r �_� . , _..� 1 /25/2021 Signature of Authorized Person (specify title Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Coffee &Art Stroll 11. Certification of Understanding(Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the CountyHawai'i,of Hawai i, I (we) understand and will complywiththe requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific,. measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of awai`i Nonprofit Grant Application FY2021®22 Agency Name: -\ va\va f i \\ay. OVbAr . • Program Name: C cee, X V\`"-\ C� a\\ �._.._._...�.-...'. ..... "-2Tsl.3+ry.m^Awi�-�°.4TH:T.�u=✓-.� 'cr"'3.-tid.".w.:i. ` ^_Lt.-�eaw::RC'3}s��T^..2�..u.�-r L." W +w W+..'2C_w.Z.CC".. .��r...,v.✓.u's'�i .i. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of l-iawai'i Finance Department,which specificall+,;and explicitly indicates that the County of Hawaii is an ' additional,insured prior to receiving any payment(s). I (we) understand thatfailureto submit the-final=report within=60-days.of.June•30h shall result in loss of all grant funds received during thegrant period (must be refunded toCounty) and exclusion from future grant participation for minimum of one year or until a written repot is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report Information and instructions are available at.littp:;/\''dlaJ?i'�i,ha`!l aiicou?�lM1)I_gp lin-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and Overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will ir17•act the evaluation o _ our a0enc 's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Cap.61 Improvements (Cost of Construction, materials;°insurance or securities) on,private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. (( 1 3 1 ?AL k 5ignatureorized Person Date joer W(O PifQ.S16Guixt- Title/Position of Authorized Person EXHIBIT A , ' NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 7 of 8 1 1 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Coffee &Art Stroll 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of attendees (difficult to determine 2500 Number of participating coffee farmers .30 Number of negative comments or criticisms 0 Number of negative comments or criticisr 0 TABLE II: FY 21-22 . Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 5,000 Operations Supplies 1 ,1 00 Equipment 500 Other: Permit 0 Other: Logo Items 0 Other: Safety 400 Other: Other: TOTAL 7000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Holo aloa Village `Ghana Music & Light Festival 144 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Holualoa Village Ohana Program Name:Music & Light Festival Agency Director: Jaelyn Rockman Phone No.:(808 )640 —4094 Contact Person: Clare Wilson Phone No.:(808)322 —7094 Mailing Address: Address: Post Office Box 100 Address: City,ST,Zip Holualoa, HI 96725 Facility Address: Address: Address: City,ST,Zip Email Address: clarewilson98@gmail.com Fax No.: (808 ) 322 —7094 Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua 0 North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes 0 Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities - ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Music & Light Festival 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 7150 2300 2.Agency Mission Statement: The mission of the Holualoa Village Ohana is to preserve the historical importance of Holualoa and the village heritage as well as provide opportunities to promote the area's coffee growing heritage,artistic assets,and cultural traditions through the organization of educational community events. 3. Program Description: What started out 22 years ago as a way for community members from upcountry to gather together in town for a holiday party has turned into a community event with over 1200 attendees strolling through Holualoa Village.Last year,due to the COVID-19 pandemic,the celebration was reduced to a display of lights and music for the community to enjoy as they drove through the village during the holiday season. This year we are hoping to return to the tradition of starting the holiday season by bringing together community members to enjoy their town,local businesses,and celebrate the season with friends old and new.Community members and visitors alike stroll the village while enjoying the light displays and holiday music. The shops and galleries along the main street are bright with holiday lights and decorations and a large Christmas tree is set up in front of the Holualoa School Resource center. Trays of cookies and refreshments are set out to welcome guests,and musicians such as john Keawe and the Big Island Academy of Music keep alive the tradition of Hawaiian holiday music throughout the village.After cruising through town in classic car,Santa arrives to take a seat in is chair and hear requests of the children.Each child visiting Santa receives a gift and parents can take pictures of their child with Santa. We recognize that if the pandemic is still a problem,adjustments will need to be made to the activities. 4.Total Budget&Position Count: Total Program Budget: 5,425 Total Program Position Count: Total Agency Budget: 11 ,000 Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: music & Light Festival 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Membership Dues 300 Funds raised at Coffee & Art Festival 650 Donations _ 300 TOTAL: 1 150 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Request more donations Increase membership 7. Program Objectives Using County Nonprofit Grant Program Funds: More and better quality gifts for the keiki Increase number of musicians/groups to cover more of the village A safe celebration EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Music & Light Festival 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific) Every keiki gets to talk to Santa and receives a gift Observe Percentage of galleries that participate 90% Number of complaints from participants 0 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 1 ,500 1 ,500 Operations 0 350 350 Supplies 0 650 650 Equipment 0 400 400. Other: Keiki gifts 0 900 900 Other: Event insurance 0 325 0 Other: Permit 0 100 0 Other: Advertising 0 500 500 Other: Safety/Security 0 .700 700 TOTAL 0 5,425 5,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Music & Light Festival 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted.. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 Member or members of the Council O Staff appointed by a member of the Council O The Mayor • The Managing Director A The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: JJ If no conflicts exist, check here. AA (A)1M Q ,,, , 1 /25/2021 U-Signature of Authorized Person (specify title) Date g ( p fY EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Holualoa Village Ohana Program Name: Music & Light Festival 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the reauirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: \A o\ vat �a\f1-1�a�� a - Program Name: \ 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (.we) understand that failure to_submitthe final report.within.60 days of June 30t!'.,shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report.'Information and instructions are available at hteri://wti° �'«7 hawaiicourit .gcyLfn_'non €;: it_oTa 1!is rrls;_.on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (ti0%)for administrative and overhead costs..Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. r Awards cannot provide funds for Capital Improvements(Cost of Construction, materials; insurance or securities)on private properties unless otherwise authorized by law. . By signing below, you.are acknowledging that you have read and understood these requirements. I1i3I7 2-1 Sig ure of a thorized Person Date ?(PS ikP Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 - 2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency 9 Name: Holualoa Village Ohana g Program Name: Music & Light Festival 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees 1 ,500 Operations 350 Supplies 650 Equipment 400 Other: Keiki gifts 900 Other: Event insurance 325 Other: Permit 100 Other: Advertising 500 other: Safety/Security 700 TOTAL 5425 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Homeless Task Force dba 808 Homeless Task Force Fab Rehab Program 145 1 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Homeless Task Force, dba 808 Homeless Task Force Program Name:Fab Rehab Program Agency Director: Regina Weller, Executive Director Phone No.:(808 ) 315 -4158 Contact Person: Regina Weller Phone No.:( ) - Mailing Address: Address: p,0. Box 731 Address: City,ST,zip Captain Cook, Hawaii 96704 Facility Address: Address: 82-6077 Mamalahoa Hiahwav Address: City,ST,Zip Captain Cook, HI 96704 Email Address: 808htf@gmail.com Fax No.: ( ) - Accountant/CPA: Cindy Hanna Phone No.:(808) 990 -5831 Firm (if applicable): Affordable Business Services Mailing Address: Address: 75-341 Aloha Kona Drive city,sr,zip Kailua Kona, Hawaii 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua []North Kona ❑South Hilo ❑North Kohala Ej South Kona ❑North Hilo ❑South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑■ Youth Q Victims of Crimes ❑ Cultt{re and the arts 0 Aged • ©Victims of Health or Social Crises El Needs of the poor Q Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Ilawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,000 $24,624- 2.Agency Mission Statement: The Mission of the Homeless Task Force is to assist the homeless in West Hawaii by providing Outreach and • Engagement Services that would begin the process of providing each individual with specific safe haven options that would set the tone for a productive pathway back into main stream society,where possible. This includes introducing the homeless to our services as their potential pathways off the street,tailored to their individual needs,that will ultimately direct them into safe haven options of:housing,of family reunification and return home,or into drug and alcohol rehabilitation facilities. We will assist them with goals and a plan that will upgrade their lifestyle and well-being, The added stressors that the current Covid-19 pandemic has imposed on this unsheltered community necessitates the importance of"canvassing"through West Hawaii to seek out individuals to offer them immediate aid. Our experience, expertise and success in decreasing the number of homeless in a given community is rooted in the strength of "connecting"with our Clients. After 25 years of experience with the homeless issue in the Mainland,our mission remains the same:"to help the disenfranchised,the wounded and the homeless to regain their hope,dignity and self-reliance." We transferred our 501 c3 nonprofit operations here in Hawaii in April of 2019 and we have since taken 32 people off the street. 3. Program Description: Fab Rehab Program After a survey of the Island,it is evident that a large percentage of the homeless have untreated drug and alcohol addictions. The Housing First model that our organization supports is low barrier and open to all in that it does not preclude people with present addictions to enter housing,however,the infrastructure here on the West side does not provide wrap around services that include avenues for drug and alcohol rehabilitation. Therefore,the revolving door is on going,with homeless entering interim housing and then back out on the street,with no betterment or change to his or her circumstances. Many on the street have staph infection and other transmittable diseases,and many are not wearing facemasks or committed to the Covid safety precautions. They trail into more crime,poor health,jail,or death. There are quality drug and alcohol resources in operation on the West side,however they are limited in their scope of service: facilities that require clients to have insurance,or their clients must fit into a specific category covered by federal funding (i.e.,as those that assist newly released prisoners),or the existing programs are always filled to capacity and there is a long waiting list. There are simply not enough places to get support. The 808 Homeless Task Force sees a serious need to provide direct assistance to clients through one-on-one counseling and referrals to available resources. With this Fab Rehab program,we will hire one(1)trained and Certified Drug and Alcohol Counselor/Facilitator to assist with this growing,perilous problem on the West side,Hawaii. Our Organization respectfully requests that the Council consider the immediate impact that this rehabilitation venture would have in West Hawaii,and accommodate funding accordingly. 4.Total Budget&Position Count: Total Program Budget: (44,440 Total Program Position Count: 1 Total Agency Budget: 375,387 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate West Hawaii Real Estate Association 2021 Upcoming Fundraiser $500 Private donations $1,000 TOTAL: 1,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Through applying for Hawaii State Grants for 2021 -2022,and Hawaii foundation grants,searching out Grant data base, and by Church contributions. 7. Program Objectives Using County Nonprofit Grant Program Funds: In this current proposal,we are committed to offering Drug and and Alcohol Counseling and Rehab resource referrals to those in the homeless community that would benefit from this service. The Drug and Alcohol staff facilitator will canvas the areas that the homeless frequent to open up the conversation,introduce the program and hand out program cards to those that might be interested. The count of those who might undergo counseling is not yet determined,however we can expect to search out recovery settings,and provide referrals and place at least 10 into a residential drug and alcohol treatment center. Additionally the funds will be used to hire and train 1 Certified Drug and Alcohol Counselor/Facilitator who will assist in this role and function. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific) We can measure success through a count of those that accepted counseling,a count of those that were given referrals,and those that were placed in drug and alcohol residential treatment. This program will provide, direct counseling to homeless clients by an Drug and Alcohol Counselor/Faciliator. We will hire 1 experienced Facilitator. Data will be documented on excel sheets and through HMIS data entry and maintained as required. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $ 35,000 35,000 Professional Fees 1,000 Operations 3,150 3,120 Supplies 1,520 1520 Equipment Other: phones, communications 800 800 Other: travel fare/Uber rides to various resources x 20 4,000 4,000 Other: Other: Other: TOTAL 44,440 44,440 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program W. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0. If no conflicts exist,check here. a2ge eiti 01 /28/2021 Signature of Authorized Person(specify title) rec. Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25;,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii'i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by.the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountvgov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. -. ,/ _— January 20, 2021 Signature of Authorized Person Date Regina Weller, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Fab Rehab Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • Those homeless accepting help will be given counseling, and 10 at least 10 will be placed in residential drug and alcohol treatment centers. A Counselor/Facilitator will be hirG(for this program. TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $35,000 Professional Fees 1,000 Operations 3,150 Supplies 1,520 Equipment Other: 800 Other: 4,000 Other: Other: Other: TOTAL $44,440 Additional Council directives regarding award: • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Homeless Task Force dba 808 Homeless Task Force Outreach and Engagement, "A Vision For You" Program 146 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Homeless Task Force, dba 808 Homeless Task Force Program Name:Outreach and Engagement, "A Vision For You" Program Agency Director: Regina Weller, Executive Director Phone No.:(808 ) 315 —4158 Contact Person: Regina Weller Phone No.:( ) — Mailing Address: Address: P.O. Box 731 Address: City,ST,Zip Captain Cook, Hawaii 96704 Facility Address: Address: 82-6077 Mamalahoa Highwav Address: City,ST,Zip Captain Cook, HI 96704 Email Address: 808htf@gmail.com Fax No.: ( ) — Accountant/CPA: Cindy Hanna Phone No.:(808) 990 —5831 Firm (if applicable): Affordable Business Services Mailing Address: Address: 75-341 Aloha Kona Drive City,ST,Zip Kailua Kona, Hawaii 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua Q North Kona ❑South Hilo ❑North Kohala 0 South Kona ❑North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth El Victims of Crimes ❑ Culture and the arts Q Aged Q Victims of Health or Social Crises El Needs of the poor Q Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,000 $24,624 2.Agency Mission Statement: The Mission of the Homeless Task Force is to assist the un-sheltered in West Hawaii by providing Outreach and Engagement Services that would begin the process of providing each individual with a specific vision for change that would set the tone for a productive pathway back into main stream society,where possible. This includes introducing the homeless to our services as potential pathways off the street tailored to their individual needs that will ultimately direct them into safe haven options. The added stressors that the current Covid-19 pandemic has imposed on this unsheltered community necessitates the importance of"canvassing"through West Hawaii to seek out families and individuals to offer them immediate aid. Our experience,expertise and success in decreasing the number of homeless in a given community is rooted in the strength of our Outreach and Engagement efforts. After 25 years of experience with the homeless issue in the Mainland,our mission remains the same:"to help the disenfranchised,the wounded and unsheltered to regain their hope,dignity and self-reliance." We transferred our 501 c3 nonprofit operations here in Hawaii in April of 2019 and we have since taken 32 people off the street. 3. Program Description: Our Homeless Task Force Organization understands the validity of going out to"where our potential clients are"to acquire insight and knowledge of their individual behaviors and habitat,and to experience a"human connection"between the homeless individual and the Outreach Staff Worker. In Outreach,we get a view of the loners,the seniors on the outskirts,the small camps independent on their own,the families living with children in their cars,and among them are those that might be willing and ready to accept the services we offer and potentially make the transition out of their unprotected and compromising lifestyle. The possibility of any productive change,however,only begins when this interaction takes place,whereby the homeless individual readily perceives that the visit is an act of benevolence,and that the Staff Worker has left the comfortable confines of the workplace and has entered the homeless habitat to engage in an act of goodwill. From the onset,we take measures to gain their trust and meet their most immediate specific needs. Outreach then becomes the leeway into comfortable,even cordial dialogue. All too often,the importance of this interaction is undervalued,and can be a most critical factor in catapulting the client out from their homeless situation. This is not something that can always successfully take place behind a desk,especially since there are those living on the street that will never venture into an office,simply because of mistrust,or because they've had a previous unsuccessful experience in the office-type setting. In the homeless person's mindset,the very fact that"Someone has come out to where I stay",can change the dynamics for a more purposeful visit,often breaking down the barriers that may exist in a bureaucratic office setting. It also eliminates the waiting line so that impatience and frustration is lessened. Moreover, there is a greater reason to be out there:to seek out the fragile,to acquire a better view of their specific circumstances, and offer on-the-spot assistance and guidance without the limitations found in some government programs. Outreach is an arduous task in an uncontrolled setting,and Outreach Workers must be specialty trained to meet the challenges involved in approaching singular homeless and even those in camps. Training will ensure better safety,better rapport agii) 4.Total Budget&Position Count: Total Program Budget: 164,967 Total Program Position Count: 4 Total Agency Budget: 375,387 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate West Hawaii Real Estate Association 2021 Upcoming Fundraiser $20,000 Wilcox Foundation $10,000 Private donations $25,000 TOTAL: 55,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Through applying for Hawaii State Outreach Grants for 2021 -2022,and Hawaii foundation grants,and Church contributions 7, Program Objectives Using County Nonprofit Grant Program Funds: We expect to provide awareness and give hope to the Homeless population in West Hawaii in the way of direct and immediate services to assist them out of the cycle of homelessness. We expect to train Outreach and Engagement staff workers in our methodology and implementation process that has proven to be highly successful in motivating those on the street into healthy directives that would promote their physical,emotional and mental state. It is especially warranted and imperative in this time of Covid to offer measures that would amplify their safety. It is our desire with the grant funds to interview and assess 100 people,and encourage and stabilize a minimum of 40 into specific safe haven options that would enhance their health and well-being,and their return to mainstream society to become productive members,where possible. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY202 1.-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) We expect that the homeless we have met through Outreach and Engagement°A Vision For You°assessment will ultimately be placed into the safe haven options of:Interim,transitional,or permanent housing,and others we wit refer to the appropriate resources as needed. Others will return home to their families of origin out-of-state through the RetumHome/Family Reunification process.We will purchase vehicles for those desiring employment,and assist with searching through the labor force for employment.Those requiring drug and alcohol rehabilitation and counseling will be provided with referrals and rides to enrollment interviews and their scheduled entry into drug programs.We will provide case management and maintain follow-up care at scheduled 1,3,6 months and 1 year intervals.We can measure success through a count of those we met,the goals they achieved,and a count of those that accepted and progressed in safe haven options. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $ 139,240 120,000 Professional Fees 3,000 2,500 Operations 4,177 2,000 Supplies 1,100 1,100 Equipment 1,500 1,500 Other: Hygiene kits, facemasks 3,500 3,500 Other: Food cards, water 2,500 2,500 Other: Costs to support client upgr 12,000 10,000 Other: Clothing/shoes 2,000 1,500 Other: Covid info pamphlets 350 250 TOTAL 164,967 144,850 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or•administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the fallowing(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: gi If no conflicts exist,check here. kP1/11>/. 01/28/2021 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • January 28, 2021 Signature of Authorized Person Date Regina Well, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Outreach and Engagement, "A Vision For You" Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Outreach to 100 homeless individuals and families 100 Document ready status for 30 individuals 30 Data entry of 100 people into HMIS and CES systems 90 Intensive Case Management for 50 individuals 50 Training of 3 new staff personnel to conduct Outreach 3 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $120,000 Professional Fees 2,500 Operations 2,000 Supplies 1,100 Equipment 1,500 Other: Hygiene kits, facemasks 3,500 Other: Food cards, water 2,500 Other: Costs to support client upq§ 10,000 Other: Clothing/shoes 1,500 Other: Covid Info pamphlets250 TOTAL $144,850 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Homeless Task Force dba 808 Homeless Task Force Return to Work Program 147 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Homeless Task Force, dba 808 Homeless Task Force Program Name:Return to Work Program Agency Director: Regina Weller, Executive Director Phone No.:(808 ) 315 -4158 Contact Person: Regina Weller Phone No.:( ) - Mailing Address: Address: NI Box 731 Address: City,ST,zp Captain Cook, Hawaii 96704 Facility Address: Address: 82-6077 Mamalahoa Highway Address: City,sr,zip Captain Cook, HI 96704 Email Address: 808htf@gmail.com Fax No.: ( ) — Accountant/CPA: Cindy Hanna Phone No.:(808) 990 -5831 Firm (if applicable):Affordable Business Services Mailing Address: Address: 75-341 Aloha Kona Drive City,ST,Zip Kailua Kona, Hawaii 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua 0 North Kona ❑South Hilo 0 North Kohala Q South Kona ❑North Hilo ❑South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth 0 Victims of Crimes ❑ Culture and the arts ©Aged Q Victims of Health or Social Crises © Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,000 $24,624 2.Agency Mission Statement: The Mission of the Homeless Task Force is to assist the un-sheltered in West Hawaii by providing Outreach and Engagement Services that would begin the process of providing each individual with specific safe haven options that would set the tone for a productive pathway back into main stream society,where possible. This includes introducing the homeless to our services as potential pathways off the street tailored to their individual needs that will ultimately direct them into safe haven options of housing,family reunification/return home to their families of origin,into drug and alcohol rehabilitation facilities,and assisting them with goals and a plan that would upgrade their lifestyle and well-being,including purchase of vehicles for travel to and fromemployment.The added stressors that the current Covid-19 pandemic has imposed on this unsheltered community necessitates the importance of"canvassing"through West Hawaii to seek out families and individuals to offer them immediate aid. Our experience,expertise and success in decreasing the number of homeless in a given community is rooted in the strength of"connecting"with our Clients. After 25 years of experience with the homeless issue in the Mainland,our mission remains the same:"to help the disenfranchised,the wounded and the homeless to regain their hope,dignity and self-reliance." We transferred our 501c3 nonprofit operations here in Hawaii in April of 2019 and we have since taken 32 people off the street,and purchased 4 vehicles for family use. 3. Program Description: Return to Work Program- The lack of Rapid Transit availability and lack of a personal vehicle makes it difficult to maneuver around the West side, Hawaii. Adequate rapid transit for commuters is just not a reality.With the steep terrain and unpaved roads,the average person cannot travel by bike or on foot to places of new or continuing employment. As a solution to these obstacles our "Back to Work"Program supports the purchase of pre-owned vehicles for motivated clients. One of the best ways for homeless to return to the job market and become self-sufficient is through the purchasing of used vehicles that enable them to do so. Our 808 Homeless Task Force Organization is the only one on the Big Island that offers vehicles to clients to enable their mobility off the street and to quickly upscale from their dismal circumstances into promising ventures. It enables individuals and families to pursue work,attend job interviews and also retain their employment. Most employers expect potential new hires to have their own vehicles to ensure work reliability. Moreover,employment is crucial toward the next step of seeking housing,so that reporting your monthly wages on a rental application is giving the landlord reasonable assurance that the monthly lease can be met. With the constant flow of people moving off island,a market of used vehicles for sale already exists so that availability is certain. Our Staff Vehicle Acquisition Facilitator will search the market for vehicles that would meet the client's particular needs,interact with the Seller,and assist with DMV filing and transfer of title. Our network includes an Auto Mechanic business that pre-checks the vehicle for reliability prior to purchase.The Staff Facilitator will also look into the job pool to better assist the Client with employment that fits his or her skill set. All 4 that we purchased cars for in 2020 found employment and remain employed to this date and are self-sustaining and have secured permanent housing. 4.Total Budget&Position Count: Total Program Budget: 73,520 Total Program Position Count: 1 Total Agency Budget: 375,387 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate West Hawaii Real Estate Association 2021 Upcoming Fundraiser $1,000 Wilcox Foundation $1„000 Private donations $8,000 TOTAL: 10,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Through applying for Hawaii State Grants for 2021 -2022,and Hawaii foundation grants,and Church contributions 7.Program Objectives Using County Nonprofit Grant Program Funds: In this current proposal,we are committed to seeking vehicles for purchase to donate to 12 unhoused clients using the funds through this Grant. Through these vehicles,the Client will have the mobility to pursue employment and keep employment and have the means then to secure housing. This avenue has proven to help clients and their families to become self-sustaining. Additionally the funds will be used to hire and train 1 Vehicle Acquisition Facilitator who will assist in this role and function. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they hove participated in your program?Describe,be specific) We can measure success through a count of those we purchased vehicles for and those that found employment,as well as their success thereafter with housing. We will also record other milestones. We will contact at 1 month,3 months and 6 month intervals and 1 year. It will all be documented through excel sheets and through HMIS data entry and retained in accordance with retention requirements. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY zo-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $ 28,080 25,000 Professional Fees 1,000 Operations Supplies 820 820 Equipment Other: vehicles purchases x 12 people 43,200 43,200 Other: DMV docs/safety checks 420 420 Other: Apparel (for job interviews) Other: Other: TOTAL 73,520 69,440 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of lIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 0 If no conflicts exist,check here. 01 /28/2021 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program i�.Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I(we) have the authority and ability to fully administer the program(s)pursuant to law. I(we)understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we)understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document, Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I(we)understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report,using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I(we)understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). t (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by.the council. I(we) understand there is no provision for further notification to submit the final report.information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 28, 2021 Signature of Authorized Person Date Regina Weller, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Return to Work Program 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 12 unsheltered people will be given vehicles to seek jobs 12 Through this avenue,12 people will acquire employment 10 Hiring and training of 1 Vehicle Acquisition Facilitator 1 TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages $28,080 Professional Fees 1,000 Operations Supplies 820 Equipment Other: vehicle purchases x 12 43,200 Other: 420 Other: Other: Other: TOTAL $73,520 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Homeless Task Force dba 808 Homeless Task Force Safe Haven Options Program: Housing and Return Home 148 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Homeless Task Force, dba 808 Homeless Task Force Program Name:Safe Haven Options Program: Housing and Return Home Agency Director: Regina Weller, Executive Director Phone No.:(808 ) 315 -4158 Contact Person: Regina Weller Phone No.:( ) — Mailing Address: Address: P.O. Box 731 Address: City,ST,ZIP Captain Cook, Hawaii 96704 Facility Address: Address: 82-6077 Mamalahoa Highwav Address: City,ST,Zip Captain Cook, HI 96704 Email Address: 808htf@gmail.com Fax No.: ( ) — Accountant/CPA: Cindy Hanna Phone No.:(808) 990 —5831 Firm (if applicable): Affordable Business Services Mailing Address: Address: 75-341 Aloha Kona Drive City,ST,Zip Kailua Kona, Hawaii 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona ❑North Hilo ❑South Kohala ❑.Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth 0 Victims of Crimes 0 Culture and the arts 0 Aged 0 Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of I3awai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,000 $24,624 2.Agency Mission Statement: The Mission of the Homeless Task Force is to assist the un-sheltered in West Hawaii by providing Outreach and Engagement Services that would begin the process of providing each individual with specific safe haven options that would set the tone for a productive pathway back into main stream society,where possible. This includes introducing the homeless to our services as potential pathways off the street tailored to their individual needs that will ultimately direct them into safe haven options of housing,family reunification/return home to their families of origin,into drug and alcohol rehabilitation facilities,and assisting them with goals and a plan that would upgrade their lifestyle and well-being.The added stressors that the current Covid-19 pandemic has imposed on this unsheltered community necessitates the importance of"canvassing"through West Hawaii to seek out families and individuals to offer them immediate aid. Our experience,expertise and success in decreasing the number of homeless in a given community is rooted in the strength of "connecting"with our Clients. After 25 years of experience with the homeless issue in the Mainland,our mission remains the same:"to help the disenfranchised,the wounded and the homeless to regain their hope,dignity and self-reliance." We transferred our 501G3 nonprofit operations here in Hawaii in April of 2019 and we have since taken 32 people off the street. 3. Program Description: We've learned over time that productive change only comes about when the needs of the"whole"person are addressed. This includes housing,where a roof over one's head offers safety and rest,where hygiene is attainable,where addictive behaviors are addressed,and self-sufficiency becomes foremost. There is no major progress without it,and so we are focused on the greater goal of giving the client latitude from their present misery,and giving them hope and a possible way out of their unprotected and dangerous lifestyle. There are two viable options presented here that offers a"roof over their head"and supports the transition into a more healthy productive lifestyle:The first is entry into Transitional, Interim or Permanent Housing,and secondly,the Return Home/Family Reunification option. Under our Housing Program,we will seek out housing options in the private and public sector,collaborate with other housing resources,engage with landlords, and assist with initial housing entry fees. In 2019 our efforts were successful with the placement of 14 into housing on the Big Island,Hawaii. In this current proposal,we are committed to seeking placement for 12 into available housing. The second option in the Safe Haven Program is the Return Home to families of origin.Our 808 Homeless Task Force organization's commitment to family reunification is unparalled.We currently are the only organization on the Big Island that is setting a course for the homeless to return back home to their families and we have the years of experience and expertise in this viable process that promotes healthy communication and emotional healing for our clients and their families. Families are initially contacted by phone to ensure that the client's return is plausible and agreed to prior to purchase of travel fare. We also include a background check through the Kona Police Department to ascertain that there are no hindrances or encumbrances such as warrants,or other factors. The City Prosecutors office then provides the subsequent checks and clearances prior to Client departure. We are committed in this proposal to provide the means for 15 people(including the pets)to return home to their families. Two trained Safe Haven Facilitators will be available to assure the completion of services and placement of a total of 27 clients through this Safe Haven Program. 4.Total Budget&Position Count: Total Program Budget: 92,460 Total Program Position Count: 2 Total Agency Budget: 375,387 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home 5, Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate West Hawaii Real Estate Association 2021 Upcoming Fundraiser $4,000 Wilcox Foundation $2,000 Private donations $6,000 TOTAL: 12,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Through applying for Hawaii State Grants for 2021 -2022,and Hawaii foundation grants,and Church contributions 7. Program Objectives Using County Nonprofit Grant Program Funds: In this current proposal,we are committed to seeking placement for approximately 12 unsheltered into available housing using the funds through this Grant. The second option of the Safe Haven Program is the Return Home to families of origin,and we are committed using the Grant funds to return 15 people to their families to accommodate their care. This usually involves a return out-of-state so that plane fares are included,as well as travel fare for any pets. It is especially warranted and imperative in this time of • Covid to offer these measures that would amplify the health and safety of these individuals. Additionally the funds will be used to hire and train 2 Safe Haven Facilitators who will assist in this role and function. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Placement of the 12 individuals into housing will be followed up by case management at 1,3,and 6 month intervals,and then 1 year. We will provide follow-up care by phone call to those Clients that returned home to their families of origin,and also speak with the attending family members at the follow-up intervals of 1 month and 6 months.We can measure success through a count of those we interviewed and serviced in the Safe Haven Program,there desire to stay housed,their actual progress and achiavments with their. goals.It will all be documented through excel sheets and through HMIS data entry and retained In accordance with retention requirements. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $ 56,160 51,000 Professional Fees 1,000 800 Operations 2,000 2,000 Supplies 650 500 Equipment 800 500 Other: Travel fare/luggage x 15 people for return home 9,000 9,000 Other: Housing entry fees/security dep/for 8 -12 people 20,000 20,000 Other: Apparel (to support colder climates) 1,500 1,000 Other: Food cards for 27 1,350 1,350 Other: TOTAL 92,460 85,350 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 0 If no conflicts exist,check here. �--- 01 /28/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home i. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one yearor until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.govgn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. , � January 28, 2021 Signature of Authorized Person Date Regina Weller, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Homeless Task Force, dba 808 Homeless Task Force Program Name: Safe Haven Options Program: Housing and Return Home 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 15 people will return home to families of origin 15 12 people will enter housing 12 Hiring and training of 2 new staff Safe Haven Facilitators 2 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $51,000 Professional Fees 800 Operations 2,000 Supplies 500 Equipment 500 Other: Travel fare/luggage x 15 9,000 Other: Housing Entry fees x 12 20,000 Other: Apparel (for cold climates) 1,000 Other: Food cards for 27 people 1,350 Other: TOTAL $85,350 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hold la Veteran Services Growing Veterans: Incubator Farm 149 wool eitrouin G--,rv County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'ola Veteran Services Program Name:Growing Veterans: Incubator Farm Agency Director: Emily Emmons Phone No.:(808 )494 —2613 Contact Person: Emily Emmons Phone No.:(808 )494 —2613 Mailing Address: Address: 923 Kukuau St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Nahala St Address: City,ST,Zip Hilo, HI 96720 Email Address: emily@hoolafarms.org Fax No.: ( ) — Accountant/CPA: Kulea Tax & Financial Services Phone No.:(808 ) 315 —2144 Firm (if applicable): Mailing Address: Address: 17 Furneaux Lane Suite 206 City,sr,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $11,450 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑I Hamakua 111 North Kona 0 South Hilo North Kohala ❑■ South Kona Q North Hilo ❑■ South Kohala Ka u Services or Activities To Be Provided: (One or more can be checked) E] Educational concerns ❑Youth ❑Victims of Crimes D Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 \kco\cx,v-0-viro.,n zryi c e County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ho'ola Veteran Services Program Name: Growing Veterans: Incubator Farm 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0 $5,700 2.Agency Mission Statement: Ho'la Veteran Services 501c3,d.b.a.Ho'Ia Farms(HVS)provides agriculture training and hands-on experiences for veterans and their families in hopes of creating a more sustainable future&well-being for all.Our program combines proven agricultural training for commercial production with essential health and human services to support veterans in their entrepreneurial ventures and personal lives. 3. Program Description: Ho' ola Farms Ag Incubator program will be operating a small market farm in partnership with Big Island veteran farmers to produce fresh vegetables and herbs for local sale as well as value-added products made from ingredients that we grow. This is an important phase in our overall initiative,GoFarm Hawaii:Growing Veterans, to assist those veterans in our community who wish to become farmers and producers in the agriculture sector.Our first growing season will begin February 2021 and produce will be available for purchase starting in April 2021. Our veteran farmer partners include those who have recently graduated from the GoFarm Hawaii program and we are seeking support in the form of field and/or nursery equipment that they will need access to in order to continue growing. Support for this program helps participating veterans continue to contribute to rural prosperity and achieve an enhanced quality of life for themselves,and their families. The objectives of this project are to 1)provide continued to engage and support veteran graduates from AgXcel program through the AgIncubator Program,and 2)engage with 75 veterans,caregivers,and families throughout the community through our volunteer program which will strengthen the network of veterans recruited for the next cohort of veteran participants actively working in agriculture in Hawai` i County.HVS will prioritize engagement of transitioning veterans, disabled veterans,women,underemployed veterans,and military families. This project is non-duplicative of existing initiatives and provides an innovative approach to addressing the challenges veterans face transitioning into civilian life and the workforce after service.The project involves a high level of engagement with an active network of stakeholders to provide recruitment and qualified referral support.The nuhlir•.-nrivatp nartnnrshin drivinn this nrnisct is a strafe mndal far atIMP.ss as HVS and( FH can levarana their 4.Total Budget&Position Count: Total Program Budget: $34,945 Total Program Position Count: 3 Total Agency Budget: $255,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2023.-2022 Page 2 of 8 • • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ho'ola Veteran Services Program Name: Growing Veterans: Incubator Farm 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate USDA/NIFA AgVets Grant Award$251,000 Annually,year 2 in grant cycle $21,145 TBI Warrior Foundation-$1,000 $1,000 In-Kind Contributions-$2150 $2150 TOTAL: 24,295 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The pilot project will be sustained beyond the project period through continued collaboration and partnership of the applicant and GFH.The GFH farmer training program has been institutionalized at University of Hawai` i for five years, and has a robust program along with the operational and administrative structure needed to secure additional federal, state and private funding to replicate this program for veterans at all GFH training sites across the state. Hole is actively pursuing other sources of funding from philanthropic foundations and individual donors to secure funding to continue operating this program in Hawaii i County and potentially support expansion to the neighbor islands. 7. Program Objectives Using County Nonprofit Grant Program Funds: Growing Veterans:Agincubator program will be operating a small market farm in partnership with Big Island veteran farmers who have recently graduated from the GoFarm Hawaii program to produce fresh vegetables and herbs for local sale as well as value-added products made from ingredients that we grow.We are seeking support in the form of field and/or nursery equipment that they will need access in order to continue growing. Significant outcomes projected i)veterans have increased their knowledge and basic farm skills ii)increase the number of veterans who apply to future cohorts of AgXcel and AgPro. Engagement of third-party evaluator Dr.Roxana Delgado will ensure results from this project interface with similar work being conducted on a national level.A final assessment will be conducted to make recommendations to prepare the program for replication statewide. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 Vsaoi c£ KOU(\ gvAri ce3 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'ola Veteran Services Program Name:Growing Veterans: Incubator Farm 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeosuring what happens for the Participants after they have participated in your program?Describe,be specific.) and families through workshops&volunteer farm opportunities 75 ngaged an additlona175 veterans,caregivers, 9 Continued technical and hands-on support to veteran graduates of the GoFarm Hawaii AgXcel progam 4 ' Increased the number of veteran applicants apply for GoFann programs and other agriculture programs in Hawai' I County 4 a Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $10,740 $2,000 Professional Fees • $10,000 $3,000 Operations $1,350 $0 Supplies $2,600 $1,250 Equipment $10,255 $5,200 Other: Other: Other: Other: Other: TOTAL $34,945 $11,450 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 . 148010., V e,-k-?xa n S-exV ice' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'ola Veteran Services Program Name:Growing Veterans: Incubator Farm io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): • Member or members of the Council Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist,check here. ?figAihe : 01 /29/2021 ature of At horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 oto'010 M as\Sexvi c-es County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'ola Veteran Services Program Name:Growing Veterans: Incubator Farm 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 •x'01 G�, V X ch?YVI Gel/ County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'ola Veteran Services Program Name:Growing Veterans: Incubator Farm 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ? (2°"3"/ nature of Auth ized Person Date ,fes 4071- - d 4 Ike//r n !L// cej Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 'VW o t( Ve, tarn S-eY v c.2,5 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ho'ola Veteran Services Program Name:Growing Veterans: Incubator Farm 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Engaged an additional 75 veterans,caregivers,and families through workshops&volunteer fano opportunities 75 Continued technical and hands-on support to veteran graduates of the GoFann Hawaii AgXcel progam 4 Increased the number of veteran applicants apply for GoFarm programs and other agriculture programs in Hawai i County 4 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,000 Professional Fees $3,000 Operations $0 Supplies $1,250 Equipment $5,200 Other: Other: Other: Other: Other: TOTAL 11,450 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HOPE Services Havvai`i, Inc. Permanent Supportive Housing 150 'I' County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing Brandee Menino $ Agency Director: Phone No.: (8Cij1931§— 3050 Contact Person: Brandee Menino Phone No.: (80E0936— 3050 Mailing Address: Address: 357 Waianuenue Avenue 8 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 357 Waianuenue Avenue Address: City,s-r,Zip Hilo, HI 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: ( ) — Accountant/CPA: Shelly Toledo Phone No.: (8Q6 75a— 3244 Firm (if applicable): Mailing Address: Address: 357 Waianuenue Avenue City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 20,000.00 Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua UI North Kona 0 South Hilo 0 North Kohala 0 South Kona El North Hilo El South Kohala Li Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑I Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged 0 Victims of Health or Social Crises Q Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A N/A 2.Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE) delivers on its mission to "Bring to life the gospel values of justice, love, compassion and hope through services, empowerment and advocacy" through a continuum of services including mobile outreach, street medicine, emergency and transitional shelter, housing placement, rental assistance, permanent supportive housing, and case management. Since our inception as a nonprofit affiliate organization in 2010, we have expanded our service capacity, and evolved to identify and serve the most economically- and socially-disadvantaged populations: delivering data-informed, evidence-based programs and services with both compassion and outcome-based efficiency, and building a robust system response to homelessness to serve families and individuals at risk of and experiencing homelessness. 3. Program Description: The Permanent Supportive Housing Program provides support to chronically homeless individuals and/or families in stability and recovery. The Program assists participants to obtain and secure long-term permanent housing consistent with the Housing First Approach, and provides necessary support to maintain housing and prevent recidivism, or returns, to homelessness. With the ultimate goal of permanent housing placement, sustainability and housing stabilization, the provides housing assistance, case management, and direct or referral services to assist participants locate housing, navigate unit inspection and leasing, transition and move-in, and maintain housing stability. 4.Total Budget & Position Count: Total Program Budget: $ 1,848,995.27 Total Program Position Count: 20 Total Agency Budget: $ 13,829,364.15 Total Agency Position Count: 115 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State Housing First Program 825,000.00 Federal Kukui Program 9 518,329.00 0 Program Income 64,534.45 TOTAL: $ 1,407,863.45 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Permanent Supportive Housing is supported by state and federal resources, however the rental assistance is limited by state and federal budgets which cannot always meet the needs of individuals and families experiencing chronic homelessness - who require longer-term supports. The COVID-19 pandemic has exacerbated the vulnerability of this high-needs population. Alongside providing supported services for those experiencing homelessness, HOPE engages in systemic solutions including advocacy at the State and Federal level to not only sustain, but increase, core homeless services including Permanent Supportive Housing. We will continue to search and apply for government and private grants through foundations, the philanthropic community, and fundraising events to help sustain this critical program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our agency-wide objective is to make homelessness rare, brief, and nonrecurring. HOPE staff will assist high needs participants end their episode of homelessness through accomplishing the following service delivery goals: 1) During initial intake all participants will be certified as homeless, making them eligible for rental assistance and case management services; 2) Establish meaningful and accomplishable housing-focused goals. 3) Increase positive social capital through coordinating outside services and resources appropriate to each person's needs, strengths and goals. 4) Obtain greater financial stability and independence through earned income, and by maximizing mainstream benefits. 5) Maintain a supportive relationship with participants to support them in retaining permanent housing once they have been successfully housed. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) The three metrics that matter most to HOPE are: Per staff of Council Member Lee Loy on 1/21, 1)Reducing the length of stay in homelessness This column was left in the application inadvertently 2)The exit rate to permanent housing,thus ending the homeless episode Thus,we were instructed not to enter data. 3)The rate at which participants remain successfully in housing HOPE measures participant stabilization and safety for up to 12 months following program exit which is documented in the State Homeless Management Information System(HMIS) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $823,323.46 $848,023.16 $ 5,000.00 Professional Fees $44,208.99 $45,535.26 Operations $ 113,644.64 $117,053.98 Supplies $ 13,000.00 $ 13,390.00 Equipment $ 3,050.68 $ 3,142.20 Other: Housing Assistance (rent/utilities) $851,767.50 $877,320.53 $ 15,000.00 Other: Other: Other: Other: TOTAL $1,848,995.27 $1,904,465.13 $20,000.00 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 AgencyName: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator ofo y ur organization may have with the County of Hawai I. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict t exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X‘f If no conflicts exist, check here. V.2-414-/ Si 'ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer thes ro rampursuant p g ( ) to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. di/2.1-Aly Sig ture of Authorized Person Date Ex `c.c Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Permanent Supportive Housing 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants exiting program into permanent housing 50% Participants who have exited and retained housing for 1 year 85% Participants who have increased non-cash income 20% TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 HOPE Services Havvai`i, Inc. Prevention Assistance 153 County of Hawaii Nonprofit Grant Application FY2021-22 AgencyHOPE Services Hawaii, Inc. Name: Program Name: Prevention Assistance Agency Director: Brandee Menino Phone No.: ( (8Q69319— 3050 Contact Person: Brandee Menino Phone No.: (8( ) 9361— 3050 Mailing Address: Address: 357 Waianuenue Avenue Address: City,ST,zip Hilo, HI 96720 Facility Address: Address: 357 Waianuenue Avenue Address: City,ST,zip Hilo, HI 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: ( ) Accountant/CPA: Shelly Toledo Phone No.: (8Q:1)755— 3244 Firm (if applicable): Mailing Address: Address: 357 Waianuenue Avenue city,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 20,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑� Puna ❑� Hamakua Q North Kona ❑■ South Hilo • North Kohala 0 South Kona ▪ North Hilo South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts Q Aged 0 Victims of Health or Social Crises • Needs of the poor 0 Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A N/A 2.Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE) delivers on its mission to "Bring to life the gospel values of justice, love, compassion and hope through services, empowerment and advocacy" through a continuum of services including mobile outreach, street medicine, emergency and transitional shelter, housing placement, rental assistance, permanent supportive housing, and case management. Since our inception as a nonprofit affiliate organization in 2010, we have expanded our service capacity, and evolved to identify and serve the most economically- and socially-disadvantaged populations: delivering data-informed, evidence-based programs and services with both compassion and outcome-based efficiency, and building a robust system response to homelessness to serve families and individuals at risk of and experiencing homelessness. 3. Program Description: In our homeless response system, prevention is a critical intervention to stop people from becoming homeless, and prevent their entering into the homeless response system. When homelessness can be prevented through reunification with family or community - occasionally requiring support to re-establish ties, and coordinate inter-island or out-of-state travel to return home - or by helping people to stabilize where they are, the Prevention Assistance program delivers right-kind, right-sized solutions. When families and individuals don't yet meet the State prevention criteria, but their unique circumstances mean imminently falling into homelessness, helping to offset existing household costs is more rapid, cost-effective, and less traumatizing than waiting for all of the chips to fall. Prevention assistance may include providing gas cards, grocery store gift cards, or helping to reunite people with their friends, family, and community off-island. 4.Total Budget& Position Count: Total Program Budget: $ 46,350.00 Total Program Position Count: 1 Total Agency Budget: $ 13,829,364.15 Total Agency Position Count: 115 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Kaiser Foundation $5,000.00 Private donations $2,500.00 O'Neill Foundation $15,000.00 TOTAL: $ 22,500.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Prevention Assistance is an ongoing expense, offered at no-cost to program participants. Client Assistance is an ineligible expense within Federal and State contracts, however, the benefits of preventing entering homelessness for people not yet eligible for State Prevention programs saves in the long-run, and reduces added trauma on families and individuals. Prevention assistance is afforded through private unrestricted funding and philanthropic support. We anticipate that, particularly with the ongoing pandemic, critical and emerging needs of persons at imminent risk of homelessness will only continue to grow, thus we have projected a budget 3% higher than last fiscal year. We will continue to search and apply for government and private grants through foundations, the philanthropic community, and fundraising events to help sustain this critical program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our agency-wide objective is to make homelessness rare, brief, and nonrecurring. Families and individuals served by this program are those who are not yet eligible for other rapid support, including COVID-19 supports, nor State prevention support. HOPE staff will prevent families with children and adults in entering the homeless response system by establish trust and rapport with persons at imminent risk of homelessness, and help prevent their falling into homelessness. 1) Helping families and individuals identify solutions to retain current housing 2) Providing support to ensure their safe housing, or 3) Helping reconnect families and individuals to return to family, friends and community when those ties are off-island, and when reunification will mean an end to homelessness. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants of the Prevention Assistance Program will remain housed and/or be reunified with Per staff of Council Member Lee Loy on 1/21, family,friends and community,thus preventing their falling into homelessness. This column was left in the application inadvertently HOPE follows up within a month of assistance to check in on families and individuals,and offers Thus,we were instructed not to enter data. continued assistance,or verifies eligibility for any other program,depending on need. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Client Assistance $45,000.00 $46,350.00 $20,000.00 Other: Other: Other: Other: TOTAL $45,000.00 $ 46,350.00 $20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 1 If no conflicts exist, check here. 14-41-8.‘"h) S'gnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 i County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 0 //a /a/ S' nature of Authorized Person Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: HOPE Services Hawaii, Inc. Program Name: Prevention Assistance 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Households whose homelessness were prevented with short-term immediate assistance 75% Households who stabilized after receiving prevention assistance 75% TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hospice of Kona Maluihi Grief Center- Community Bereavement Program 154 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hospice of Kona Program Name:Maluihi Grief Center- Community Bereavement Program Agency Director: Laura Varney Phone No.:(808 )324 —7700 Contact Person: Adriana DeGress Phone No.:(808 )329 —8202 Mailing Address: Address: P.O. Box 4130 Address: City,ST,Zip Kailua-Kona, HI 96745-4130 Facility Address: Address: 75-5925 Walua Road Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: adegress@hospiceofkonafoundation.org Fax No.: (808 )331 —8477 Accountant/CPA: Christine Winn Phone No.:(808 ) 324 —7700 Firm (if applicable): Mailing Address: Address: P.O. Box 4130 • City,ST,Zip Kailua-Kona, HI 96745-4130 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Q Hamakua loll North Kona EI South Hilo 0 North Kohala Q South Kona Q North Hilo Q South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth Q■ Victims of Crimes O Culture and the arts 0 Aged l Victims of Health or Social Crises O Needs of the poor IN Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 9,675 8,375 2.Agency Mission Statement: Hospice of Kona provides family-centered support,education and care for those approaching the end of life. Hospice of Kona's Foundation exists to provide sustainable support for the future of Hospice of Kona. (draft) We Believe That the Hospice philosophy enhances quality of life; That Hospice service is a personal entitlement option; In providing the highest quality of compassionate care; That fear of the unknown can be overcome with education and caring; In respect for individual beliefs; In supporting bereavement throughout the community; In maintaining an excellent,educated staff; In being a financially responsible organization. 3. Program Description: Hospice of Kona's Malu'ihi Grief Center(Maluihi meaning to be in a safe peaceful environment,treated with respect to prepare for a sacred peaceful journey safe from Kapu.)is simply a space that allows healing to occur through grief counseling and groups for youth and adults. The center named for Elizabeth Maluihi Lee,a cultural historian and one of Hawaii Islands living treasures is located in the historic Nakamaru farm house. Bereavement services include an annual community event,The Circle of Remembrance,grief support groups,individual counseling and an annual Youth grief event known as Camp Erin. There is no doubt that 2020 has brought grief in ways above and beyond anything we could have expected. Loss is everywhere and when the loss of life is added to the loss of work,the loss of home,the loss of normal than the loss must be handled with additional compassion. Our team is learning to provide compassion,sympathy and resources without contact. Our support group clients have adapted to sharing their grief into a camera and watching themselves and others as they come together and stay apart. 4.Total Budget& Position Count: Total Program Budget: 165,000 Total Program Position Count: 4 Total Agency Budget: 3,401,916 Total Agency Position Count: 33 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 • Agency Name: Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Contributions/Individual and Corporate 25,000 Solicited campaigns and Fund development 50,000 Grants 90,000 TOTAL: 165,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: -Social media campaigns -Annual Appeal -Virtual Fund Development Events -Solicited individual donations from clients requesting to give back and support program -Expanding our reach through Social Media to share the work our programs successes 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective is to continue to provide our bereavement services at Malu'ihi Grief Center at no cost to our clients. To continue to increase capacity through the use of volunteers and outreach. Funding through the County of Hawaii to our programs will allow our team to continue to say yes we can to clients as other organizations are saying no we cannot. With the use of virtual counseling;we are able to reach the families of the clients we serve regardless of whether they live in our service area or out of our physical reach. EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are yourneasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Bereavement Surveys are sent to all participants Send 500-1000 surveys(compile results) Individual clients prepared to advance to group setting 50 clients continue to support group Clients coming back to volunteer,provide testimonials and support future bereaved 12-20 clients Attach additionala es as necessary. 9 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 78,000 105,000 15,000 Professional Fees Operations 21,459 21,500 5,000 Supplies 1,883 2,000 Equipment Other: Cleaning and Maintenance 1,638 2,500 Other: Support Group Meeting Food 1,112 1,000 Other: Annual Memorial Event 7,575 8,000 5,000 Other: Camp Erin -Youth Grief Camp 6,174 25,000 Other: TOTAL 117,841 165,000 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Laura Varney POSITION: CEO May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): • fl Member or members of the Council EI Staff appointed by a member of the Council I] The Mayor ❑] The Managing Director OI The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. /-02_ 7 Signature of Authorized Persortjsjpecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ,:A47c2 7 —oZ d 1-7 Signature of Authorized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Hospice of Kona Program Name: Maluihi Grief Center- Community Bereavement Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Bereavement Surveys are sent to all participants Send 500-7000 surveys(compile results) Individual clients prepared to advance to group setting 50cllents continue to support group Clients coming back to volunteer, provide testimonials and support future bereaved 12 - 20 clients TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 105,000 Professional Fees Operations 21,500 Supplies 2,000 Equipment Other: Cleaning and Maintenance 2,500 Other: Support Group Meeting Fcti 1,000- Other: Annual Memorial Event 8,000 Other: Camp Erin -Youth Grief Ca 25,000 Other: TOTAL 165,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hui ['Via-lama Ola Na `Oiwi Koktaa Hall Specialty Para Transit 158 1� County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Specialty ParaTransit Agency Director: S. Lehua Andrade Phone No.: ( 808) 969 — 9220 Contact Person: Nicole Moore Phone No.: ( 808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Address: City,ST,Zip Email Address: nicole@hmono.org Fax No.: (808) 961 — 4794 Accountant/CPA: Phone No.: ( 808) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop St.,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,600 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua ❑✓ North Kona ✓❑South Hilo ❑✓ North Kohala ❑✓ South Kona ✓❑ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Specialty ParaTransit 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 17-18 FY 18-19 FY 19 -20 $13,500.00 $38,975.00 $17,000.00 2.Agency Mission Statement: Mission Statement: 'O Hui Malama Ola Na`Oiwi. (We are the group that takes care of the health of Hawaiian people.) Eia ke kuleana: Ho'oulu ola ka lahui Hawai'i. (Our mission is uplife the health of the Hawaiian Nation.) Malama is Moku o Keawe, (We will take care of Hawaii Island,) Malama i na kua`aina, (Country and rural areas,) Malama i kou olakino,(Your physical, spiritual and mental body,) Malama i na mea Hawai'i. (And Hawaiian culture and practices.) E ho'oikaika a ola ka lahui Hawai'i. (We envision a strong and health.Hawaiian nation.) Values: Hui Malama Ola Na`Oiwi,its Board of Directors,Administration and Staff are guided and directed by Na Kopuna(our elders) with widone and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: Ke Akua Mana—Existence of a higher power Lokahi—Harmnoy,parity and balance 'Ohana—Family:core, intermediate and extended Po`okela—Excellence Ho'omau—Lifelong learning with guaranteed life for generations to come 3. Program Description: The Hui Malama Ola Na'Oiwi (HMONO) Kokua Hali Specialty ParaTransit program is an initiative helping Hawaii County community members who have no other means of transportation and are unable to walk without assistance of durable medical equipment(DME) (e.g.wheelchairs,walkers,crutches, canes)or visually-impaired clients requiring a blind walking stick, arrive safely and on-time to their health-related appointments and also return home safely. The Hui Malama Ola Na'Oiwi Transportation Specialist,trained in First Aid and Standard CPR,schedules the transportation appointment, selects and drives the appropriate paratransit vehicle,accompanies and assists the client from time of pickup to drop-off to ensure safe and on-time departure and arrival. HMONO has a fleet of two wheel-chair accessible vehicles:one with gurney-capable lift and the other with 4-wheel drive. Both vehicles can accommodate large types of DME that would otherwise be impossible or challenging for a regular type of vehicle. The HMONO KOkua Hali Specialty ParaTransit services are free of charge to the transported,however many passengers pay a"donation". HMONO is in the process of applying for a PUC license.Due to limited resources,all Kokua Hali Specialty ParaTransit services must be to,and from,an agency, person(s),or business whose purpose is to provide medical-related services(e.g.dental appointment, laboratory,pharmacy,physical&occupational therapy, physician visit,traditional healing practitioner). HMONO adheres to all CDC, Hawai'i State and County recommendations and mandates for COVID-19.There is a two passenger limit per vehicle in order to meet the physical distancing mandates.Vehicles are disinfected before, after and during each transport for the safety of the passengers and the Transportation Specialist. 4.Total Budget& Position Count: Total Program Budget: $269,605 Total Program Position Count: 3 Total Agency Budget: $3,384,837 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Specialty ParaTransit 5. Program Funding Sources(identify all sources of funding applied to this program): FY20-21 Revenue Source Estimate Health Resource Services Administration (HRSA) $209,005 County of Hawaii $45,600 Service Revenue $15,000 TOTAL: $269.605 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Mama Ola Na'Oiwi (HMONO)has received guidance from HMSA and other insurers on submitting transports for reimbursements. HMONO has used their guidance to establish a reimbursable rate required for the PUC license.The PUC license application has been started and once HMONO's application is approved and a license is received,we will work to contract with the insurance agencies to receive reimbursement for services. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Kokua Hali Specialty ParaTransit program currently has a part-time manager and two full-time drivers who service the entire island. Funding is needed to support one of the full-time drivers position. The organization has two specialty vehicles equipped for wheelchair transportation, as well as a seven passenger Toyota Sienna designated for the program. Due to COVID-19 mandates, only two passengers and a driver are allowed per vehicle.This has increased the number of trips because we can no longer schedule several passengers per trip and with the required disinfecting of the vehicles before,during,and after transports it is vital that we maintain both full-time driver positions. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi • Program Name: Kokua Hall Specialty ParaTransit 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Transportation Specialist(1.0 FTE) 2 Hilo residents receiving paratransit for health-related services 70 Ka'0 residents receiving paratransit for health-related services 20 Kona residents receiving paratransit for health-related services 30 North Hawaii residents receiving paratransit for health-related services 30 Puna residents receiving paratransit for health-related services 40 Number of transportation"stops"annually i,400 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 19-20 FY 20-21 FY 20-21 Actual* Total Budget Grant Req Salary and Wages $143,333 $188,533 $45,600 Professional Fees Operations $37,616 $75,232 Supplies $2,920 $5,840 Equipment Other: Other: Other: Other: Other: TOTAL $183, 869 $269,605 $45,600 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hall Specialty ParaTransit 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. %,ft1 (2. %t& ekeetaiPen,4-eder 01 /29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Specialty ParaTransit 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Specialty ParaTransit i1. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2021 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Costs of Construction, materials, insurance or securities). By signing below,you are acknowledging that you have read and understood these requirements. 9 : 01 /29/2021 Signature of Authorized Person Date eiCePLA key •Ultril4r)f Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hall Specialty ParaTransit 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Transportation Specialist (1.0 FTE) 2 Hilo residents receiving paratransit for health-related services 70 Ka'u residents receiving paratransit for health-related services 20 Kona residents receiving paratransit for health-related services 30 North Hawaii residents receiving paratransit for health-related services 30 Puna residents receiving paratransit for health-related services 40 Number of transportation "stops" annually 1,400 TABLE II: FY 20-21 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $45,600 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $45,600 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hui IVIalama Ola Na Ladies' Night Out 159 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out Agency Director: S. Lehua Andrade Phone No.: ( 808) 969 — 9220 Contact Person: Nicole Moore Phone'No.: ( 808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Address: City,ST,Zip Email Address: nicole@hmono.org Fax No.: (808) 961 — 4794 Accountant/CPA: Phone No.: ( 808) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop St.,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,250 Geographical Areas To Be Served: (One or more can be checked) ✓0 Puna ❑✓ Hamakua ❑✓ North Kona ✓❑ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out 1. Prior Year Award of County Nonprofit Grant Program Funds: FY17-18 FY18-19 FY19 -20 $4,375 $5,925 $0 2.Agency Mission Statement: Mission Statement: '0 Hui Malama Ola Na'Oiwi. (We are the group that takes care of the health of Hawaiian people.) Eia ke kuleana: Ho'oulu ola ka lahui Hawaii. (Our mission is uplife the health of the Hawaiian Nation.) Malama is Moku o Keawe,(We will take care of Hawaii Island,) Malama i na kua'aina, (Country and rural areas,) Malama i kou olakino, (Your physical, spiritual and mental body,) Malama i na mea Hawai'i. (And Hawaiian culture and practices.) E ho'oikaika a ola ka lahui Hawai'i.(We envision a strong and health Hawaiian nation.) Values: Hui Malama Ola Na'Oiwi,its Board of Directors,Administration and Staff are guided and directed by Na Kupuna(our elders) with widone and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: Ke Akua Mana—Existence of a higher power Lokahi—Harmnoy,parity and balance 'Ghana—Family: core, intermediate and extended Po'okela—Excellence Ho'omau—Lifelong learning with guaranteed life for generations to come 3. Program Description: The Hui Malama Ola Na'Oiwi (HMONO)Ladies' Night Out(LNO)is an annual wellness event for Hawai'i Island women in need. This flagship community event promoting self-care and positive self-esteem,occurs annually. Prior to COVID-19 HMONO partnered with community agencies who service underprivileged women,to distribute guest tickets to female clients, 18-years of age or older,who would not normally afford to partake in an evening of self-care or"pampering"activities,and who might benefit from a three-hour evening of free health and wellness attention. Due to pandemic, 2020 LNO changed from a face-to-face event,to a drive thru event. Registration for this event was done on-line and in-person (following CDC guidelines),with registrants receiving an electronic ticket.They presented their tickets on the night of the event and received a bag that contained:breast self-exam kits; information on common household cleaning products that contain cancer causing chemicals;non-carcinogenic laundry soap sample;stress balls/barbells;disposable and cloth face masks;disposable gloves;ingredients and recipe for a quinoa salad to be prepared at home;gardening starter kits with vegetable seeds and la'au starters(olena and/or ti);mamaki tea; bio freeze samples; printed materials that included diabetes&hypertension self-management information,cancer prevention awareness, stress management suggestions, health education class schedules and flyers.Also included was COVID-19 materials that included hand washing recommendations,correct mask wearing pictures/handout, and a FAQ sheet. This year's event will be September,24, 2021 and we are planning another drive thru event in light of the continuing pandemic. We will be working with community agencies and our clients to identify areas of need that we can address with educational materials and items that we can provide during the event.We are also planning on a distribution process working with our Community Health Workers,for participants in rural areas of the island with transportation limitations. 4.Total Budget& Position Count: Total Program Budget: $43,815 Total Program Position Count: 35 Total Agency Budget: $3,384,837 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Materna Ola Na 'Oiwi Program Name: Ladies' Night Out 5. Program Funding Sources (identify all sources of funding applied to this program): FY20-21 Revenue Source Estimate Health Resource Services Administration (HRSA) $34,565 County of Hawaii $9,250 TOTAL: $43,815 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Malama Ola Na'Oiwi(HMONO)will seek financial support from private foundations as well as continued allocation of Health Resources Services Adminsitration (HRSA)to support Ladies'Night Out(LNO)health and wellness event. Monetary donations and in-kind materials/services,will continue to support the event as well. 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will support an event that brings community providers together for one purpose in taking care of women ages 18 and older with accurate and current health and wellness information and items that they may not have access to,except through Ladies'Night Out. Funds will be used to support Ladies'Night Out to purchase: 1. Health education materials-copy paper,ink or outside printing; 2. Items to be distributed-masks,gloves,hand sanitizer, health education items, healthy food kits that include the printed recipe as well as the food products needed to prepare the recipe,small pampering items-face masks, nail kits; 3.Supplies-reusable bags,folders to hold health education materials,envelopes&postage;and 4. Facility rental -space to hold drive thru events in Hilo, Kau, Kona, North Hawaii at Puna @$250/3 hour events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of women provided with health and wellness bags-Hilo 300 Number of women provided with health and wellness bags-Ka'u 50 Number of women provided with health and wellness bags-Kona 50 Number of women provided with health and wellness bags-North Hawaii 50 Number of women provided with health and wellness bags-Puna 50 Total number of women provided with health and wellness bags 500 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 19-20 FY 20-21 FY 20-21 Actual* Total Budget Grant Req Salary and Wages $19,500 $20,000 0 Professional Fees $506 Operations $1,057 $1,065 0 Supplies $18,936 $10,000 $7,250 Equipment Other: Marketing $785 $1,500 $750 Other: Facilities $1,358 $2,000 $1,250 Other: Other: Other: TOTAL $41,602 $34,565 $9,250 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor The Managing Director n The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. / ,4 ifi4/4I, €L� 01/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2021 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Costs of Construction, materials, insurance or securities). By signing below,you are acknowledging that you have read and understood these requirements. Ateteate&it-etZ- 01 /29/2021 Signature of Authorized Person Date ere/al/At" ‘ )(-071-PY Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Ladies' Night Out 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of women provided with health and wellness bags - Hilo 300 Number of women provided with health and wellness bags - Ka'u 50 Number of women provided with health and wellness bags - Kona 50 Number of women provided with health and wellness bags - North Hawaii 50 Number of women provided with health and wellness bags - Puna 50 Total number of women provided with health and wellness bags 500 TABLE II: FY 20-21 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees Operations 0 Supplies $7,250 Equipment Other: Marketing $750 li Other: Facilities $1,250 Other: Other: Other: TOTAL $9,250 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hui IVIalama Ola Na `®iwi Physical Fitness Program - Makahiki Games 160 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na Oiwi Program Name: Physical Fitness Program - Makahiki Games Agency Director: S. Lehua Andrade Phone No.: ( 808) 969 — 9220 Contact Person: Nicole Moore Phone No.: ( 808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Address: City,ST,Zip Email Address: nicole@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: ( 808) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop St.,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $38,516 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑ Hamakua ❑ North Kona ✓❑South Hilo ❑ North Kohala ❑ South Kona ✓❑ North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ✓❑Youth ❑Victims of Crimes ✓❑ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Physical Fitness Program - Makahiki Games 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 17-18 FY 18-19 FY 19 -20 • N/A $5,050 N/A 2.Agency Mission Statement: Mission Statement: 'O Hui Malama Ola Na'Oiwi. (We are the group that takes care of the health of Hawaiian people.) Eia ke kuleana: Ho'oulu ola ka lahui Hawai'i. (Our mission is uplife the health of the Hawaiian Nation.) Malama is Moku o Keawe, (We will take care of Hawai'i Island,) Malama i na kua'aina, (Country and rural areas,) Malama i kou olakino,(Your physical, spiritual and mental body,) Malama i na mea Hawai'i. (And Hawaiian culture and practices.) E ho'oikaika a ola ka lahui Hawai'i. (We envision a strong and health Hawaiian nation.) Values: Hui Malama Ola Na'Oiwi,its Board of Directors,Administration and Staff are guided and directed by Na Kupuna(our elders) with widone and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: Ke Akua Mana—Existence of a higher power Lokahi—Harmnoy,parity and balance 'Ohana—Family: core, intermediate and extended Po'okela—Excellence Ho'omau—Lifelong learning with guaranteed life for generations to come 3. Program Description: Through the Hui Malama Ola Na'Oiwi Fitness Program's Makahiki Games project, Hawai'i youth'attending public or public-charter elementary, intermediate or high schools in the districts of Hilo, Ka'u and Puna will be introduced to Traditional Hawaiian games of the Makahiki season such as'ulu maika (bowling), moa pahee(dart sliding), hukihuki(tug of war, haka moa (one-arm,one-leg wrestling match), pa uma(hand wrestling)and kukini(swift running).The youth will learn about Makahiki game fitness skills, physiology of muscle,and exercise strategies to train for the events.The youth will also learn the mo'olelo (stories)of Makahiki legends to deepen their understanding of these sports and their appreciate of Hawaii.The specific strategy to deliver the fitness education and the'Ike Hawaii(Hawaiian knowledge)will be developed in conjunction with the administration of each school as we are currently working with their on-line delivery of curriculum during COVID-19, but will be planning on delivering the program once the schools reopens for face-to-face instruction. Although it is an online delivery of the curriculum and the keiki are unable to pair up to do the activities,our instructor is able to show them how to do the exercises and counter measures. He is able to zoom the camera to identify muscle groups that are being used and the correct positioning of their bodies.The online classrooms are interactive and the instructor is able to make real time corrections to ensure they are learning correcting and being safe. 4.Total Budget& Position Count: Total Program Budget: $49,519 Total Program Position Count: 1 Total Agency Budget: $3,384,837 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Physical Fitness Program - Makahiki Games 5. Program Funding Sources (identify all sources of funding applied to this program): FY20-21 Revenue Source Estimate Health Resource Services Administration (HRSA) $11,000 County of Hawai'i $38,519 TOTAL: $49,519 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Malama Ola Na`Oiwi will be using funds from the Health Resources Services Administration(HRSA)to fund the supplies and insurance.We will be submitting grant applications to OHA and other private foundations that have expressed interest in supporting projects that focus on youth fitness, combating childhood obesity, and Hawaiian culture-based programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: The County of Hawaii funding will support the Hui Malama Ola Na'Oiwi Fitness Program-Makahiki Games as we seek to solidify agreements with public or public-charter elementary, intermediate or high schools in the districts of Hilo, Kau and Puna. The COVID-19 pandemic has required that curriculum delivery be adjusted or in some extreme cases created to attain educational benchmarks. One of the areas that has been largely left behind is physical fitness. By using Traditional Hawaiian games of the Makahiki season such as`ulu maika (bowling), moa pahee(dart sliding), hukihuki(tug of war, haka moa(one-arm, one-leg wrestling match), pa uma(hand wrestling)and kukini (swift running)we are seeking meet this need.The youth will learn about Makahiki game fitness skills, physiology of muscle, and exercise strategies to train for the events.The youth will also learn the mo`olelo(stories)of Makahiki legends to deepen their understanding of these sports and their appreciation of Hawaii. One of the issues we hope to address is the trend of childhood obesity which has increased with the online learning platforms, which typically do not have a physical fitness component.The Makahiki Games curriculum has been revised to allow for online delivery.We are currently working with Kaumana Elementary School and are developing agreements with Keaukaha Elementary School and Kua 0 Ka La Public Charter School.We will seek to expand our network during the upcoming school years. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020- 2021 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Physical Fitness Program - Makahiki Games 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Makahiki Training sessions held 120 Unduplicated number of youth who entered training. 120 Number of keiki or`opio that increase their level of progicience of a valuable activity 120 Number of keiki or'opio that increase their frequency of practice of a valuable activity 120 Number of Memorandum of Agreements with schools 6 • Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 19-20 FY 20-21 FY 20-21 Actual* Total Budget Grant Req Salary and Wages $38,519 $38,519 $38,519 Professional Fees Operations Supplies $15,516.41 $10,000 $0 Equipment Other: Gas &Oil $500.73 $500 $0 Other: Liability Insurance $500 $500 $0 Other: Other: Other: TOTAL $55,135.81 $49,519 $38,519 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Physical Fitness Program - Makahiki Games 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council H The Mayor n The Managing Director ❑ The Director of Finance H The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. NtAalif-cee , eXtaiaGe/Died 01/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Physical Fitness Program - Makahiki Games 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Physical Fitness Program - Makahiki Games 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). • I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2021 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Costs of Construction, materials, insurance or securities). By signing below, you are acknowledging that you have read and understood these requirements. Ativic.4ficet_ca01/29/2021 Signature of Authorized Person Date exeoP' ec9w Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2020-2021 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2020-21 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Physical Fitness Program - Makahiki Games 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of Makahiki Training sessions held 120 Unduplicated number of youth who entered training 120 Number of keiki or`opio that increase their level of progicience of a valuable activity 120 Number of keiki or'opio that increase their frequency of practice of a valuable activity 120 Number of Memorandum of Agreements with schools 6 TABLE II: FY 20-21 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $38,519 Professional Fees Operations Supplies $0 Equipment Other: Gas &Oil $0 Other: Liability Insurance $0 Other: Other: Other: TOTAL $38,519 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Hui Pono Holoholona Low Cost Spay/Neuter Clinics 161 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics Agency Director: Frances P. Pueo Phone No.:(808 ) 968 —8279 Contact Person: Frances P. Pueo Phone No.:(808 )769 —1128 Mailing Address: Address: P.O. Box 943 Address: City,ST,Zip Mt. View HI 96771 Facility Address: Address: 11-3347 Waimaka 0 Pele Road Address: City,ST,Zip Mt. View HI 96771 Email Address: paws@hphhawaii.org Fax No.: ( N/A) - Accountant/CPA: Vivian Toellner Phone No.:(808) 345 —2753 Firm (if applicable): Mailing Address: Address: PO Box 6894 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND T;+ PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 51,000.00 Geographical Areas To Be Served: (One or more can be checked) ID Puna n Hamakua ❑North Kona n South Hilo n North Kohala n South Kona Q North Hilo n South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) [1 Educational concerns n Youth Victims of Crimes n Culture and the arts n Aged ❑Victims of Health or Social Crises I-1 Needs of the poor n Physical/Emotional Disabilities ■0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 12,850.00 8,375.00 9,250.00 2.Agency Mission Statement: Hui Pono Holoholona-HPH founded in 2007,as a 501c3 nonprofit servicing our community needs by decreasing humanely animal overpopulation through low cost, no cost spay and neuter. Studies show by decreasing unwanted litter births this occurs: 1.Decreases animal abandonment.2.Reduces euthanasia of healthy animals. 3. Increase fostering and adoption of altered animals. We unite dedicated volunteers for our sponsored clinics, provide support to pet owners, caregivers and other loosely formed individuals and groups caring for lost,fostering,stray,abandoned,abused,and neglected animals. People in financial difficulties,who love and care for their animals have reached out to us for help towards the cost to spay and neuter,their pets,their backyard cat colonies,and cats they care for at recycle,malls,and various locations. Education is the key to those feeding cat colonies to adopt a Trap-Neuter-Return-Manage program,a most sustainable method to manage cat colonies. In raising funds to pay for spay/neuter we do various fundraisers and apply for grants. As of this date over 7000 cats have been serviced.We put our hearts and soul in every second of every year to decrease the number of unwanted animals.Our loyal volunteers are unpaid,dedicated,giving of self and resources to increase the humane treatment of animals. In 2014 Hui Pono Holoholona established Pono Animal Way Sanctuary-P.A.W.S,a 20 acre Sanctuary for special needs felines needing a forever home. We also provide relocation for the free roaming rescued ferals here from the transfer stations,and inundated lava volcano areas. 3. Program Description: Dr.Kristina Kanani Henricks, PhD,DVM,MS,(formerly with HIHS-Hawai'i Island Humane Society)brings a tremendously needed service to our community through her new clinic"The Good Karma Spay and Neuter Clinic",located at 399 Hualani#14A, in Hilo,by appointment spay and neuter for dogs and cats every Monday,Wednesday and Friday. Dr. Henricks with her highly trained surgical Pandemic Protocol team,are able to service between 300 to 400 cats and dogs each month.This is a huge benefit to continue our S/N services during crowd gathering restrictions preventing mash type clinics.More so, Dr.Henricks has partnered with Hui Pono Holoholona in offering special low rates. In just six months 584 felines were spay/neutered there. Our partnering with Good Karma Clinic is a huge part of the solution towards decreasing animal overpopulation humanely. There are many positives with a permanent spay/neuter clinic location,such as having animals serviced as soon as possible helps to reduce pregnancies.Another advantage is Dr.Henricks and her team are available post-operative for any complications or follow up if the need should arise. 4.Total Budget&Position Count: Total Program Budget: 75,000.00 Total Program Position Count: 12 volunteers Total Agency Budget: 150,000.00 Total Agency Position Count: 4 volunteers EXHIBIT A neon Ir n NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Spay/Neuter Participants 9,000.00 Donations 2,500.00 Donation Boxes 500.00 Fundraising 2,000.00 Grant-Atherton Family Foundation—Pet Cats Only 10,000.00 TOTAL: 24,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: There is no fee or charge for our spay and neuter services. Participants are asked as a suggestion and as part of team community spirit,to donate if can,what they can,towards the spay/neuter services. It helps to service more and more cats. No one is ever turned way. Hui Pono Holoholona's sustainability of the spay/neuter program relies on grants from Hawai'i County, national animal organizations,Foundations, private donations,Social media and various fundraising activities. One grant in particular we received from The Atherton Family Foundation for$10,000,stipulates for feline Pets only,which we abide by. Other grants have no conditions attached with just S/N services for all felines in need. Hui Pono Holoholona officers are volunteers,donating their time,expenses,and services. Each year we exceed the number of cats funded for sterilization. This demonstrates a very good use of taxpayer's funds and the community's support for this service. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.)Sponsor low cost spay/neuter for the public 2.)Loan traps/pet carriers to community members at no charge. 3.)Encourage community support in the humane non-kill reduction of animal overpopulation. HPH's goal is to reduce the number strays,feral and abandoned animals, humanely in Hawai'i Island lava evacuation zones,parks and communities. The numbers of unwanted animals on Hawai'i Island are staggering. Unwanted litter births lead to animal abandonment and cruelty. Over decades rounding up to kill has proven unsuccessful and over all more expensive. Success in addressing animal overpopulation is through offering low cost/no cost spay/neuter opportunities. We support TNRM-Trap,Neuter,Return and Manage,as a humane and compassionate response to animal overpopulation and we encourage adoptions. Every animal is precious to us,whether privately owned or from a TNRM colony,and by providing spay/neuter these animals are generally healthier and safer from roaming off to mate or fight. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawail. Nonprofit Grant Application FY2021 22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Good Karma Spay and Neuter Clinic-30 surgeries a week x 52 weeks= 1,560 Attach additional pages as necessary. 9.TABLE H: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees - Veterinary S/N Surgery$42.50 per cat 22,181.00 66,300.00 47,300.00 Operations -Other Veterinary Services—Feral 0 3,500.00 0 Supplies,Traps and Carriers 1,725.00 2,000.00 2,000.00 Equipment 165,00 0 0 Other: Liablity Insurance 592.00 700.00 700.00 Other: Flea Medicine 1,055.00 2,500.00 1,000.00 Other: Spay/Neuter Surgeries,Jan 2020 to June 2020 for 25 cats 1,932.00 0 0 Other: 0 0 0 Other: 0 0 0 TOTAL 27,650.00 $75,000.00 $51,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application. FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay I Neuter Clinics 100 ORGANIZATION CONFLICT DISCLOSURE FO M Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: N/A POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): fl Member or members of the Council 1111 Staff appointed by a member of the Council OI The Mayor * The Managing Director The Director of Finance rl The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: '1 If no conflicts exist, check here. N �- January 26, 2021 Signature of Authorized Person (specify title) Date Vivian Toellner, Treasurer/Board Member EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics s1. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii granit funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). n I (we) understand that failure to submit the final report within 60 days shall exclus exclusion in from ss of all grant funds received during the grant period (must be refunded to County) and future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 26, 2021 Signature of Authorized Person Date Vivian Toellner,Treasurer/Board Member Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Good Karma Spay and Neuter Clinic:30 Surgeries a week x 52 weeks= 1,560 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees -Veterinary S/N Surgery$4250 per cat $47,300.00 0 Operations Supplies Traps and Carriers 2,000.00 Equipment 0 Other: Liability Insurance 700.00 Other: Flea Medicine 1,000.00 Other: 0 Other: 0 Other: 0 TOTAL $51,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Innovations Public Charter School Foundation Na [(alai Ola - Life Navigators - Wellness Program 167 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name:Na Kalai Ola - Life Navigators - Wellness Program Agency Director: Kiley Nakagawa Phone No.:(808 ) 331 —3130 Contact Person: Lee Nelson Phone No.:(808 ) 756 —5492 Mailing Address: Address: 75-5815 Queen Ka'ahumanu Hwy. Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-5815 Queen Ka'ahumanu Hwy. Address: City,ST,zip Kailua-Kona, HI 96740 Email Address: leenelson.ipcs@gmail.com Fax No.: (808 ) 331 —3140 Accountant/CPA: Rozanne Connell Phone No.:(808) 930 —6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: 136 Kino'ole Street City,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ❑ Hamakua ❑■ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns n Youth ❑Victims of Crimes ❑� Culture and the arts ❑Aged n Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program • 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 7,850 6,543 7,500 2.Agency Mission Statement: The mission of Innovations Public Charter School Foundation is to provide support to the Innovations Public Charter School and the West Hawaii Community by helping nurture the bodies,minds and spirits of the children of West Hawaii. Innovations Foundation provides facilities for Innovation Public Charter School. Additionally,the Foundation raises funds, has numerous outreach activities and after-school and in-school support activities for Innovations Public Charter School. Innovations Foundation strives to teach students to make responsible choices that will lead to developing strong bodies, minds and spirits. The goal of the Foundation is to support the school in nurturing children so that they may grow into responsible young adults that are community contributors and life long learners. Innovations Foundation supports on campus community gardens,sustainability initiatives(recycling/composting),art programs,fine art mentorship experiences and technology integration in education. 3. Program Description: "Na Kalai Ola-Life Navigators", recognizes the act way-finding youth will need to prepare for their destiny, understand their journey,and build the wisdom and experiences while discovering life's opportunities. "Na Kalai Ola-Life Navigators"is the metaphor for Innovations. Through a grant from the State Foundation of Culture and Arts,artist Stuart S Nakamura Studio installed a prominent feature of artwork including the iconic"lobster claw"sails of the Makali'i to depict our students as life navigators.Students study the culture and skills of navigators and relate them to the modern day culture and skills that they are developing to be successful in life. This program funds after school and in school art,drama,garden and sustainability programs. Over 60 mentors throughout the community are involved with student navigators. The students engage in expanding current indigenous and endemic gardens. With the push for common core achievement, and low per pupil funds,there is little funds available for the arts, music,garden and sustainability programs. These healthy types of activities are paramount to the overall development of our youth. Innovations Foundation is seeking support for the Na Kalai Ola program so that there are funds for after and in-school culture,arts,sustainability and garden programs to engage students in their Aina and prepare them for their life journeys. 4.Total Budget& Position Count: Total Program Budget: 90,000 Total Program Position Count: 2.5 Total Agency Budget: 500,000 Total Agency Position Count: 3 EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program • 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate REACH Program Grant 15,000 Bill Healy Foundation 10,000 Mentors In-Kind 10,000 Kohanaiki Ohana-In Kind Hawaiiana Educational Programs 10,000 County of Hawaii Grant 10,000 Innovations PCS 35,000 TOTAL: 90,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: "Na Kalai Ola-Life Navigators"is a program that ties all of our extracurricular community outreach and art,music,garden and sustainability programs together. Life Navigators key component is community involvement. Innovations relies heavily on support from the community. All seventy-two of our 7th and 8th grade students are paired with mentors in the community each Friday. This is the outreach mentorship learning part of our life navigators program. This year we have students at the following businesses more than 4 hours per week: Holy Donuts, Dolphin Quest, Humane Society, Icicles Hair Salon, Miranda's Pets, Paws,3 Ring Ranch, Roth Kimura Architecture Firm,Scandinavian Shave Ice, Keauhou Vet, Shane Dorian,Kamehameha Preschool,Aoki Plumbing,Sea Paradise, Diamond Auto, Oasis Skate Shop,Kona Vet, Island Naturals, Roy Lambrechts Woodworkers, Daylight Mind,Torpedo Tours, Miller's Surf,Yoga Hale, Holualoa El., Kealakehe El.,Soundwave Music,Sakata Archery Supplies, Inc., Creative Day and Kona Coffee and Tea Company. In addition,we have had local Rotary Support, Pohakuloa Marines and Kaiser Permanent all donating countless volunteer hours in our gardens or with health and wellness programs for our keiki.These in-kind businesses and mentors have really made a huge impact on our students and it has connected them to our community. Partnering with the community will have a long-term snowball affect for our students that will lead us to increased revenue and support as our community becomes more invested in our programs each year. • 7. Program Objectives Using County Nonprofit Grant Program Funds: The County of Hawaii Grant Program will go exclusively for our garden/sustainability programs on campus. Part of life navigation for our students is learning to treat their bodies and the Aina in a healthy and respectful manner. The garden/ sustainability program is key to the health of our keiki. All school events are zero waste and we practice"farm to fork" practices with garden class. Students not only learn to grow kale,spinach,eggplant and tomatoes, but also how to prepare vegetables for a healthy future. Due to lack of adequate funds for life programs such as art,music drama and sustainability, Innovations Foundation must fund-raise and seek grants to continue these vital programs. We,therefore respectfully request,that the County of Hawaii support our Life Navigators program so that we can navigate our students into a healthy and sustainable future. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Community Mentors to help our young student navigators in the life voyage 60 Documented Community Mentorships Volunteer Planting and Community Gardening Days 4 full days-250 in attendance Curriculum Shares Incorporating Art,Music,Drama,Sustainability 5-250 in attendance per tour Community Garden,Sustainability Tours 5-200 in attendance per tour All Students Served with Weekly Garden,Art,Music,and Sustainability Lessons 240 students per week Community Zero Waste Music and Local Grown Fruit/Pancake Breakfasts • 3-300 in attendance per event Full Culminating Performance of After School Drama Program at Aloha Theatre 900 in attendance over three days Attach additional pages as necessary. • 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 60,000 60,000 10,000 Professional Fees Operations Supplies 10,000 10,000 Equipment Other: Mentors - In Kind 10,000 10,000 Other: Kohanaiki Ohana - In Kind 10,000 10,000 Other: Other: Other: TOTAL 90,000 90,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: . POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director fl The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: RI If no conflicts exist, check here. I)00kf.�►-�S PGS 130 r 1/25/2021 Signature of Authorized Person (specify title) P Q,("c Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators -Wellness Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will'comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA • NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/25/2021 Signature of Authorized Person Date Secretary Innovations Public Charter School Foundation Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators -Wellness Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Kohanaiki Ohana- In Kind Hawaiiana Educational Programs fiO Doamented Community Men orships Volunteer Planting and Community Gardening Days 4 full days-250 in attendance Curriculum Shares Incorporating Art, Music, Drama, Sustainability 5-250 in attendance per tour Community Garden, Sustainability Tours 5-200 in attendance per tour All Students Served with Weekly Garden,Art, Music, and Sustainability Lessons 240 students per week Community Zero Waste Music and Local Grown Fruit/ Pancake Breakfasts 3-300 in attendance per event Full Culminating Performance of After School Drama Program at Aloha Theatre 900 in attendance over three days TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 10,000 Professional Fees Operations Supplies Equipment Other: Mentors - In Kind Other: Kohanaiki Ohana - In Kind Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Japanese Cultural Center of Kona Land Acquisition Due Diligence Work 170 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK Agency Director: Walter Kunitake Phone No.:( 808) 938-3624 Contact Person: Claudia Chang Phone No.:( 808 ) 938-1338 Mailing Address: Address: P 0 Box 206 Address: City,ST,Zip Kailua-Kona,HI 96745 Facility Address: Address: 76-5861 Mamalahoa Hwy,#A Address: City,ST,Zip Holualoa,HI 96725 Email Address: cscnang713@yanoo.com Fax No.: ( ) — Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) E Puna n Hamakua ❑� North Kona ❑✓ South Hilo IV North Kohala V South Kona Q North Hilo ['South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) 2 Educational concerns V Youth ❑Victims of Crimes IV] Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $14,250.00 2. Agency Mission Statement: The mission of the Japanese Cultural Center of Kona is to serve as an international,world-class gathering place to preserve and share the Japanese culture and the Kona Way of life. A few years ago, a group of current Kona residents coalesced to pursue a dream of developing a new Cultural Center to celebrate the arrival of Japanese coffee farmers on Kona's upland slopes over a hundred years ago.These new arrivals brought with them the Japanese culture that deepened the mix of cultures found in Hawaii and also resulted in Kona having its own unique way of life. They also produced a special coffee that has, over time, become renown the world over for its richness. The Japanese Cultural Center will celebrate and promote this unique heritage. In doing so, it will support Kona's longstanding bid to becoming an international gathering place. Given the Japanese cultural centers and gardens that exist elsewhere in Hawaii,this Center is planned to be of such scale, depth and variety to earn it a distinctive position in Hawaii's visitor and cultural landscape. To take advantage of Kona's weather,the complex would be powered by 100% renewable energy consistent with Hawaii's 100% renewable energy goal. It will be built with environmentally sustainable techniques and materials where possible, qualifying for LEED platinum rating. 3. Program Description: Program Description: Compensating professional due diligence work in securing an identified parcel of land for the master planned Cultural Center. The Land Acquisition Task Force of the JCCK Board was created over two years ago to begin reviewing possible parcels to accommodate development of a Japanese cultural center in the Kona district consistent with a strategic plan adopted in 2017. The Task Force comprised of Board members and professional volunteers Statewide identified over 30 parcels as possibilities. After multiple preliminary screening of the parcels based on size, dimension, location, accessibility, elevation,topography,water availability,zoning, and other characteristics, the Task Force with support from the Board, a single parcel had been identified as the best candidate for the Center and ideal for the Master Plan developed in late 2019. The Board is committed to begin official contact with the parcel's land owners. The Board is advised to perform more in-depth due diligence work over those performed thus far. Even after proceeding with a committed intent to purchase, more professional due diligence work will be necessary.Although JCCK might be able to continue to receive some pro bono work, they were more of an advisory nature. From here on, compensated fees will be necessary. The current requested funds are for fees related to professional planners, realtors, attorneys and other related experts. 4. Total Budget& Position Count: Total Program Budget: $22,000 Total Program Position Count: 0 Total Agency Budget: $39,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 AgencyName: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Golf Tournament $5,000 Banquet $10,000 Donations from Board Members/Community $2,000 TOTAL: $17,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Golf and the Banquet fundraisers will be scheduled after there is safety from controlled spreading of the Corona Virus through vaccination. JCCK held a successful golf tournament in September 2019 and a successful Banquet in January 2020 netting a combined of$35,000. JCCK will continue with such fundraising programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: With support from the County Nonprofit Grant Program, JCCK will be able to secure professional due diligence work critical in pursuing the acquisition of the targeted parcel for the Center. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? • PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Study flood zone issues Report on flood issues Research driveway access issues Engineering driveway plans EIS walk through the parcel Preliminary EIS report Water availability Well water plans owners Writingcontracts with ne s Contract documents Purchse Commitments Escrow documents Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees: Consultants per above $39,000 $22,000 Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $39,000 $22,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK a.o; ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose ariy conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.one form per person with a conflict is needed. If no conflicts exist,one form for the organization,With the"No conflicts exist'option checked needs to be submitted. Please dLiplicate aS needed to fully disclose. Ai!dissfosure forms must sl'oned,regardless of whether a cordLict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following t:cheOk all that apply): O Member or members of the Council 0 Staff appointed by a member of the Council O The Mayor El The Managing 0 irattor O The Director of finance O The Corporation Counsel,the Assistant Corporation Counsel or a Deputy Corporation Counsel confiict of interest is defined as:a swbsrant'a,pmisatiOty UNr.'-'n taken byail indliddura wt rzer msasurab le LI/raft benefits accruing r dse thrill:Jar a;opt:osed to benefits coming otrevof ineultry Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest If no conflicts exist,check here. signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page S of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County. ofHawaiiNoriproflt Grant Application FY202 I-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND, CQUISITION DUE DILIGENCE WORK ii.Certification of Understanding(Page 2 of 2) If awarded a grant from the County of I-la wail,[(we)understand that a current Certificate of Liability 134000,000 general liability,$50,000 each occurrence)must be provided to the County of hlawai`i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior tO receiving any payment(s). I(we)understan6 that failure to submit the final report within 60 days;a;June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and acceptjy the council. 1(we)understand there is no provision for further notification to submit the final report.Information and instructions are pvailable at htt irkvaiiroiirry_p,;:vrfn-nonzrriL-rlrifilt formc7 on or about may.SC of the year the final report is due. As oar't of this eppkation,you acknowledge that any funds awarded will be restricted for the purposes stated in the p pl i cgiJors,except fora maximum ten perCent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Fie,wail with the final reort,Failure to return these funds in a tirnelv racrtner-will impact The evoluotion of your agencies A..ture fundina Teeniest and may result in ertions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost.of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements, 2 4.1? Signature of of Authorized Person Date I , Title/Position of 4-thorized Person EXHIBIT A NONPROFIT GRANT APPLICATION 17;'2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: JAPANESE CULTURAL CENTER OF KONA Program Name: LAND ACQUISITION DUE DILIGENCE WORK 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Kamuela Philharmonic Orchestra Society► Elementary School Music Education Program 171 County of Hawai`i Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program Agency Director: Joel Gimpel Phone No.:(808 ) 325 —4991 Contact Person: Brenda McConnell Phone No.:(80iii) 557 —0693 Mailing Address: Address: PO Box 2597 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: Address: City,ST,Zip Email Address: grants@kamuelaphil.org Fax No.: ( ) — Accountant/CPA: Catha Lee Combs, CPS Phone No.:(808) 791 —1420 Firm (if applicable): Wikoff Combs and Co., LLC Mailing Address: Address: 1001 Bishop St. #2760 city,sr,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 10000.00 Geographical Areas To Be Served: (One or more can be checked) ❑� Puna {j Hamakua ❑■ North Kona 0 South Hilo Ei North Kohala 0 South Kona ❑■ North Hilo Q South Kohala ■0 Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑■ Youth ❑Victims of Crimes 0 Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 4300.00 0 4300.00 2.Agency Mission Statement: The Kamuela Philharmonic Orchestra Society is a non-profit organization established in 2005 which is dedicated to bringing live, high-quality orchestral music to audiences on Hawaii Island. The Kamuela Philharmonic celebrates and promotes the timeless beauty of classical music,as well as the rich cultural and musical traditions of the Hawaiian people. Through our Children's Concerts and other forms of educational and community outreach,we nurture a love and understanding of orchestral music in young people. In addition to our education and outreach programs,the Kamuela Philharmonic Orchestra provides a showcase for our talented local musicians each concert season. This organization is staffed mainly by volunteers with the help of contracted consultants. The volunteer base is well organized with seasoned and committed volunteers. 3. Program Description: Kamuela Philharmonic Orchestra Society is the only professional orchestra serving Hawaii Island. As part of it's mission statement they are committed to the education of the youth. Each month KPOS brings live music instruction into the Island public school. During 2020 the education team worked hard to get the music education programs on a digital platform that could be shared with teachers and students during the time when students worked remotely. Looking forward to the school year of 2021-22 KPOS would like to bring more music education into the elementary schools. During these visits the musicians from the orchestra would bring their instruments to the classroom and show the students how they work and play a little song for them. There would be 5-6 musicians at each visit so the students can be introduced to instruments from each"family'of an orchestra. After this introduction of each instrument the group will play a song together so the students could see how instruments work together in a group to create music. The orchestras mission is to introduce classical,symphonic music but they will also play music the students are familiar with so they can sing and clap along. Funding support from the County of Hawaii will insure that this program gets priority in the public elementary schools on Hawaii Island. 4.Total Budget&Position Count: Total Program Budget: 21,525.00 Total Program Position Count: 1 Total Agency Budget: I'3S,0(20,00 Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii 10,000 Private Donations 500.00 In-Kind Donations 11025.00 • TOTAL: 21525.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This elementary program is part of the larger overall education program which Kamuela Philharmonic Orchestra provides each year to the Hawaii Island students. There are season sponsors which help fund these programs such as Hawaii Community Foundation,The Dorrance Foundation,the Spadaro Family Foundation and the Laura Jane Musser foundation. Besides these regular sponsors of the education work KPOS does there are private donors who contribute.As word gets out about these education programs more people are willing to donate and these programs become more and more sustainable. KPOS has also been chosen by Carnegie Hall's Link-up program and this partnership will begin in 2022 providing State and County regulations for in person gatherings in schools. More information on this program: https://www.carnegiehall.org/education/educators/link-up 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Bring music into the schools help to grow students'interest in music. 2.Give them some basic understanding of what it's like to play a musical instrument to,hopefully,spark interest in further learning. 3. Introduce the instruments families. 4.Give some basic music theory. 5. Perform a classical piece of music that represents how an orchestra works together. 6.Allow the students an opportunity to participate. 7.Expose children directly to classical music in a fully rounded context. It is the hope that during these school visits the students will be inspired to play an instrument,attend an orchestral concert with live music or seek out listening to classical music on their own. Each school visit lasts the equivalent of one class period about 45-60 minutes. Many schools allow two back to back sessions to serve more students.Some schools have a gym/auditorium we can use to run the sessions.Depending on the size of the school and the number of sessions they can accommodate the reach of these visits can be 30—250 students per school per day. The orchestra is committed to one to two school visit each month depending upon school schedules and available funding. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific) Bringing live music directly into the schools to ignite an interest in learning to play an instrument. Teach what each instrument sounds like,how they are played and what family they belong to in the orchestra. Teach which instruments live in each orchestra family and who they work together to create symphonic music. Teach some basic music theory to help students understand that teaming music is Ike learning another Language which they can use to talk to otters with as they play together. Once students team what each Instrument is then when the musicians play together the students can see how each instrument layers to create the complete symphonic sound. During the performance section of the visit the students war he invited to departing along so that they get the full experience of howl feels to parhdpate in an orchestral seting. Students will take away from these sessions the understanding of how an orchestra works and hopefully will be inspired to participate somehow. Attach additional pages as necessary. "Yr MaCked. rwt 4 r .:2a5ter t-eitotiai 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 15000.00 6000.00 Professional Fees 1500.00 1500.00 Operations 2250.00 1750.00 Supplies 1500.00 750.00 Equipment 1275.00 0.00 Other: Other: Other: Other: Other: TOTAL 21525.00 10000.00 *If applicable • EXH I BIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 Kamuela Philharmonic Orchestra Society—Elementary School Music Education Program FY2021-22 Program Objectives and Outcome Each school visit will last approximately 45 min and will serve approximately 30 - 250 students per visit depending on the size of the class room or multipurpose room provided by the school. 1. Objective: Bring music into the schools help to grow students' interest in music. Outcome: Bringing live music directly into the schools to ignite an interest in learning to play an instrument. 2. Objective: Give them some basic understanding of what it's like to play a musical instrument to, hopefully,spark interest in further learning. Outcome: Teach what each instrument sounds like, how they are played and what family they belong to in the orchestra. 3. Objective: Introduce the instruments families. Outcome: Teach which instruments live in each orchestra family and who they work together to create symphonic music. 4. Objective: Give some basic music theory. Outcome: Teach some basic music theory to help students understand that learning music is like learning another language which they can use to talk to others with as they play together. 5. Objective: Perform a classical piece of music that represents how an orchestra works together. Outcome: Once students learn what each instrument is then when the musicians play together the students can see how each instrument layers to create the complete symphonic sound. 6. Objective: Allow the students an opportunity to participate. Outcome: During the performance section of the visit the students will be invited to clap or sing along so that they get the full experience of how it feels to participate in an orchestral setting. 7. Objective: Expose children directly to classical music in a fully rounded context. Outcome: Students will take away from these sessions the understanding of how an orchestra works and hopefully will be inspired to participate somehow. County of Hawaii Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 10 Member or members of the Council ❑ Staff appointed by a member of the Council 0 The Mayor ❑ The Managing Director [DI The Director of Finance D The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential 1 conflicts of interest: If no conflicts exist, check here. .....: ` tz ,, )//2.12,/ 6., )?) 2,0 ." Si: ature A thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Alk ev� ign::ture of uth ized P rson LIDate P/1,14 t444-- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Kamuela Philharmonic Orchestra Society Agency Name: Program Name: Elementary School Music Education Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Bringing live music directly into the schools to ignite an interest in learning to play an instrument. Serve up to 15 Schools Teach what each instrument sounds like,how they are played and what family they belong to in the orchestra. Serve up to 15 Schools Teach which instruments live in each orchestra family and who they work together to create symphonic music. Serve up to 15 Schools Teach some basic music theory to help students understand that teaming music is Eke teaming another language which they can use m talc to others with as they play together. Serve up to 15 Schools Once students team what each instrument is then when the musicans play together the students tan see hew each instilment layers to create the complete symphonicsounrL Serve up to 15 Schools During the performance section of the visit the studentswlll be baited to dap or sing along so that they get the fun experience of how Itfeels to participate to an orchestral setting. Serve up to 15 Schools Students will take away from these sessions the understanding of how an orchestra works and hopefully will be inspired to participate somehow. Serve up to 15 Schools TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 6000.00 Professional Fees 1500.00 Operations 1750.00 Supplies 750.00 Equipment Other: Other: Other: Other: Other: TOTAL 10000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Keaukaha One Youth Development Ho`ola Hou - Hawaiian Warriorship Program 172 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name:Ho'ola Hou - Hawaiian Warriorship Program Agency Director: Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 City,s-r,zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna ❑■ Hamakua ❑ North Kona ['South Hilo [' North Kohala ❑South Kona ❑■ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑� Youth ❑Victims of Crimes ❑� Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $8,800.00 $9,419.00 $10,125.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities. Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2) instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokaalaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The Ho'ola Hou system was founded by the late Lohe Ka'aloa to promote the warrior traditions, values, and practices of a Hawaiian martial order. Ho'ola Hou incorporates three necessary stages of learning: 1) Ho'ola hou'revitalization of the individual'; 2)Ola hou'to live revitalized'; and 3) Kia`i 'to safeguard and protect'. The Ho`ola Hou system is a martial art that incorporates various martial techniques of many traditions. Its unique style is based upon the strength and movement of our Pacific waters, and the spirit of Aloha identifies its philosophy.While effective techniques of self-defense are part of the essential training, character building and understanding the true spirit of Aloha are of greater importance. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Ho'ola Hou-Hawaiian Warriorship Program will rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Ho'ola Hou-Hawaiian Warriorship Program will strive to reach the following objectives: 1)Provide an environment suitable for youth learning about ones self and character through peer interaction. 2) Develop strong youth leaders based on native Hawaiian practices and applied values. 3) Develop confidence, self-identity, and enhanced self-esteem for efficacy. 4) Develop and deepen the competence of practitioners in Ho'ola Hou. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Daily attendance recorded to track number of youth exposed to program 50 youth Hours recorded to track time spent by volunteers for program implementation 1,920 hours ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees Operations Supplies $10,125.00 $6,000.00 $6,000.00 Equipment $6,000.00 $6,000.00 Other: Food/snacks for youth & volunteers $3,000.00 $3,000.00 Other: Travel $7,500.00 $7,500.00 Other: Other: Other: TOTAL $10,125.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ID The Mayor ❑ The Managing Director II The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: CO If no conflicts exist, check here. C LZ TWE 10/Karig/ / Edi VENA- r I?c/w%'-4 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 2_02,e `�/ Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Ho'Ola Hou - Hawaiian Warriorship Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Daily attendance recorded to track number of youth exposed to program 50 youth Hours recorded to track time spent by volunteers for program implementation 1,920 hours ***See attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500.00 Professional Fees Operations Supplies $6,000.00 Equipment $6,000.00 Other: Food/snacks $3,000.00 Other: Travel $7,500.00 Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2021-22 Keaukaha One Youth Development (KOYD) Ho`ola Hou — Hawaiian Warriorship Program Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Daily attendance recorded to track number Approximately 50 youth of youth exposed to program 2) Hours recorded to track time spent by Approximately 1920 hours (see breakdown volunteers for program implementation below): * 40 hours per month x 12 months =480 hours Hours for Executive Director, Executive per person x 4 people = 1920 hours Assistant, Fiscal/Administrative Coordinator, and Cultural Specialist Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries & Wages: Portion of Executive Director $2,500.00 Salary Supplies: Misc. training supplies $6,000.00 Equipment: Misc. training equipment $6,000.00 Food: Snacks/other food supplies $3,000.00 Travel: Intra-island travel expenses $7,500.00 for staff professional development 1 Keaukaheii One Youth Development Hokualaka'i Restoration Project 173 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project Agency Director: Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna ❑■ Hamakua ❑ North Kona ❑■ South Hilo ❑■ North Kohala ■❑South Kona ❑■ North Hilo g South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns 11 Youth ❑Victims of Crimes O Culture and the arts ❑■ Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $8,800.00 $16,000.00 $9,125.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawai'i County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe, these cultural vessels of learning will promote: (1)the stress of physical fitness; (2) instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and (5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: In November 2015,the Hokualaka'i double-hulled voyaging canoe owned and built by`Aha POnana Leo was graciously donated to KOYD and the community of Keaukaha.As the new caretakers,we decided to make Keaukaha its permanent home having been over-challenged with the restoration demands it requires.We envision this donation as another learning domain to further solidify our goals of creating cultural learning places for youth and their families to contribute their talents and learning engagements through our Polynesian voyaging heritage and to teach our youth to become qualified voyaging members of the Hokualaka'i. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 TOTAL: Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hokualaka`i Restoration Project continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Hokualaka'i Restoration Project will strive to reach the following objectives: 1) Restore the Hokualaka'i double-hulled voyaging canoe back to seaworthiness. 2)Teach the values of team work,goal setting, commitment, physical, mental, and spiritual well-being, and cultural identity through the restoration process and use of the voyaging canoe. 3)Create more cultural learning places for youth and their families to contribute their talents and learning engagements through our Polynesian voyaging heritage. 4)To inspire and teach our youth to become cultural experts in the arts of kalai wa'a(canoe restoration)and ho'okele wa'a (voyaging)through the use of Hokualaka'i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project B. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Event attendance recorded to track number of youth exposed to program 50 youth Hours recorded to track time spent by volunteers for program implementation 5,760 hours Hokualaka'i Restoration Completed by June 2022 "'See attachment Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees Operations Supplies $9,125.00 $15,000.00 $15,000.00 Equipment $7,500.00 $7,500.00 Other: Other: Other: Other: Other: TOTAL $9,125.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokaalaka`i Restoration Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council (■� Staff appointed by a member of the Council f] The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: J1 If no conflicts exist, check here. EliCtirni/E—blift-C72W/ //2319,,oZt Ly/(V14--"-/- Signature of Authorized Person (specify title) Ldi19 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka'i Restoration Project 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. IILs-f(2,2,, Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Event attendance recorded to track number of youth exposed to program 50 youth Hours recorded to track time spent by volunteers for program implementation 5,760 hours Hokualaka`i Restoration Complete June 2022 ***See attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500.00 Professional Fees Operations Supplies $15,000.00 Equipment $7,500.00 Other: Other: Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program —Attachment Fiscal Year 2021-22 Keaukaha One Youth Development (KOYD) Hokualaka`i Restoration Project Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I—Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Event attendance recorded to track number Approximately 50 youth of youth exposed to program 2) Hours recorded to track time spent by Approximately 5,760 hours (see breakdown volunteers for program implementation below): * 40 hours per month x 12 months = 480 hours Hours for Executive Director, Cultural per person x 12 people = 5,760 hours Practitioner, and 10 Keaukaha Hawaiian Homestead kupuna 3) Hokualaka`i Restoration Restoration completed by June 2022 Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II—Council Award Worksheet Program Expenditures Additional Details Budget Salaries & Wages: Portion of Executive Director $2,500.00 Salary Equipment: Outdoor power $7,500.00 tools/equipment Supplies: Misc. materials/supplies for $15,000.00 Hokualaka`i reconstruction and site maintenance 1 Keaukaha One Youth Development Junior Lifeguarding Program 174 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name:Junior Lifeguarding Program Agency Director: Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 city,sr,zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑■ Hamakua ❑ North Kona ❑■ South Hilo [' North Kohala ❑South Kona ❑■ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑■ Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ▪ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021.-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0.00 $0.00 $11 ,625.00 2. Agency Mission Statement: g Y The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities. Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The Junior Lifeguarding Program was designed to train our youth ages 12—17 in lifesaving water skills and to develop awareness of beach hazards and ocean conditions. Participants will become familiar with First Aid and CPR techniques, while improving their health and fitness. Participation in the program will result in development of team building and leadership, rescue techniques such as CPR/AED/First Aid, quick/efficient emergency response, and improved physical ability in swimming, running, strength training, and endurance. 4.Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Junior Lifeguarding Program continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Junior Lifeguarding Program will strive to reach the following objectives: 1) Provide opportunities to improve health and fitness. 2) Promote valuable skills such as teamwork and leadership to overcome life challenges. 3) Build a new generation of competent watermen and women for the future safety of our island/ocean communities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Daily attendance recorded to track number of youth exposed to program 30 youth Hours recorded to track time spent by volunteers for program implementation 515 hours Lifeguard Certification Events Participation of all qualified age groups ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees $5,000.00 $5,000.00 Operations Supplies $11,625.00 $8,000.00 $8,000.00 Equipment $5,000.00 $5,000.00 Other: Food/snacks for youth & volunteers $2,000.00 $2,000.00 Other: Travel $2,500.00 $2,500.00 Other: Other: Other: TOTAL $11,625.00 $25,000.00 $25,000.00 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor ❑ The Managing Director Ii The Director of Finance ❑� The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 4&//1/L-`---41 -Emu pi: rots/iu' Signature of Authorized Person (specify title) /4 ti7'' 'Wf Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ff2-(1—(2VZI Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Junior Lifeguarding Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Daily attendance recorded to track number of youth exposed to program 30 youth Hours recorded to track time spent by volunteers for program implementation 515 hours Lifeguard Certification Events Participation of all qualifietl age groups ***See attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500.00 Professional Fees $5,000.00 Operations Supplies $8,000.00 Equipment $5,000.00 Other: Food/snacks $2,000.00 Other: Travel $2,500.00 Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program —Attachment Fiscal Year 2021-22 Keaukaha One Youth Development (KOYD) Junior Lifeguarding Program Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Daily attendance recorded to track number Approximately 30 youth of youth exposed to program 2) Hours recorded to track time spent by Approximately 515 hours (see breakdown volunteers for program implementation below): * 4 two hour junior lifeguarding training days Hours for Executive Director, Program per month x 12 months = 96 hours x 4 Assistant, Two (2) Program Interns volunteers = 384 hours * 4 eight hour Saturday lifeguard certification events x 4 volunteers = 128 hours 3) Lifeguard Certification Events Participation of all qualified age groups and certifications received Reference to Page 4, Question 9: Table II—Program Expenditures Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Professional Fees: Stipend to Junior Lifeguard $5,000.00 Instructor Equipment & Supplies: Various equipment and $13,000.00 supplies Other: Travel Costs (to certification $2,500.00 events) Snack/other food supplies $2,000.00 1 Keaukaha One Youth Development PISCES -VEX IQ Robotics Program 175 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name:PISCES - VEX IQ Robotics Program Agency Director: Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) Q Puna 0 Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑South Kona ❑■ North Hilo ❑ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) El Educational concerns El Youth Ei Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0.00 $9,416.00 $9,625.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe, these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka`i double hulled sailing canoe; and (5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: In September 2017, through a new collaboration with the Pacific International Space Center for Exploration Systems (PISCES),the PISCES-VEX IQ Robotics Program was established to provide opportunities of innovation, design, competition and future interest in science,technology,engineering, and math (STEM)fields. Students engage with two UH-Hilo interns that help train them to conduct computer programming and construction of robots engineered to perform specific tasks to overcome challenges and game like gauntlets such as those seen in the annual Waiakea-Hilo-Honokaa (WHH)VEX IQ League which they have participated in year school year since 2018. 4.Total Budget & Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES -VEX IQ Robotics Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 TOTAL: Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The PISCES-VEX IQ Robotics Program continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The PISCES-VEX IQ Robotics Program will strive to reach the following objectives: 1)Provide opportunities of innovation, design, competition and future interest in science,technology, engineering, and math(STEM)fields. 2) Promote valuable skills such as critical thinking and problem solving to overcome life challenges. 3)Create more opportunities to utilize STEM in KOYD's current and future culture-based programs EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Daily attendance recorded to track number of youth exposed to program 30 youth Hours recorded to track time spent by volunteers for program implementation 575 hours VEX IQ Robotics Events Participation of all qualified age groups ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees Operations Supplies $9,625.00 $8,000.00 $8,000.00 Equipment $5,000.00 $5,000.00 Other: Food/snacks for youth & volunteers $2,000.00 $2,000.00 Other: Travel $7,500.00 $7,500.00 Other: Other: Other: TOTAL $9,625.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council i• Staff appointed by a member of the Council LI The Mayor ❑ The Managing Director 0 The Director of Finance 111 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. � 11 &Tab) al oud(/ 2s1?-0'� Signature of Authorized Person (specify title) F,i/b671," Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. f/2_�7-2o 2/ Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: PISCES -VEX IQ Robotics Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Daily attendance recorded to track number of youth exposed to program 30 youth Hours recorded to track time spent by volunteers for program implementation 575 hours VEX IQ Robotics Events Part cipatin of all qualified age groups ***See attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500.00 Professional Fees Operations Supplies $8,000.00 Equipment $5,000.00 Other: Food/snacks $2,000.00 Other: Travel $7,500.00 Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2021-22 Keaukaha One Youth Development (KOYD) PISCES —VEX IQ Robotics Program Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I—Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Daily attendance recorded to track number Approximately 30 youth of youth exposed to program 2) Hours recorded to track time spent by Approximately 575 hours (see breakdown volunteers for program implementation below): * 4 two hour robotics training days per month Hours for Executive Director, Program x 12 months = 96 hours x 4 volunteers = 384 Assistant, Two (2) Program Interns hours * 6 eight hour Saturday robotics competition events x 4 volunteers = 192 hours 3) VEX IQ Robotics Events Participation of all qualified age groups and top rankings achieved Reference to Page 4, Question 9: Table II—Program Expenditures Reference to Page 8, Question 12: Table II—Council Award Worksheet Program Expenditures Additional Details Budget Salaries & Wages: Portion of Executive Director $2,500.00 Salary Equipment & Supplies: Various robotics equipment $13,000.00 and supplies Other: Travel Costs (State Robotics $7,500.00 Competition) Snack/other food supplies $2,000.00 1 Keaukaha One Youth Development RISE 21st Century After School Program 176 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name:RISE 21st Century After School Program Agency Director:, Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna Hamakua ❑ North Kona g South Hilo ❑ North Kohala ❑South Kona Q North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,050.00 $14,750.00 $10,125.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities. Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and (5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The RISE 21st Century After School Program was established in 2011 by Keahi Warfield and Naomi Ahu to serve as a community resource bank for underprivileged, Native Hawaiian youth ages 8-18 in the Hilo district.The main focus is to aid in revealing their individual strengths and passions for future career and academic success.A variety of mediums are used to build Individual Student Success Plans(ISSP)such as but not limited to: apprenticeships, Hawaiian cultural practice, internships, multimedia, performing arts, project exhibitions, student exchange,and work study initiatives. RISE also provides opportunities to support physical well-being, cultural identity, and leadership. By implementing this mission, RISE envisions that when the youth participants graduate from high school,they will have a clear and stronger idea of what their future career and academic pursuits will be. The relationships they have gained through our program will help motivate and encourage them to become valuable contributors to the well-being and sustainability of the Hilo community. 4. Total Budget& Position Count: Total Program Budget: $175,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 Kamehameha Schools-Community Investing(pending) $100,000.00 Hawaii Community Foundation-Career Connected Learning(pending) $50,000.00 TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The RISE 21st Century After School Program continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our key objectives for youth success are the following: 1)To reveal the strengths and passions of youth participants to contribute toward overall student engagement and confidence. 2)To help youth participants develop Individual Student Success Plans(ISSP)to track monthly goals and expectations and to contribute toward building responsible, respectful and reliable students. 3)To implement Hawaiian cultural practices such as the art of ho'ola hou (restoration discipline)and ho'okele/hoe wa'a (canoe voyaging/paddling)to teach values and encourage discipline, balance, and leadership for physical, mental, and spiritual well-being. 5)To incorporate STEM (science, technology, engineering, and mathematics)principles in the cultural/place-based learning domains we have access to. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Daily attendance recorded to track number of youth exposed to program 75 youth Hours recorded to track time spent by volunteers for program implementation 2,520 hours Individual Student Success Plans used to track youth interests and goal setting 100%youth begin development of ISSP ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $1,000.00 $100,000.00 $2,500.00 Professional Fees $5,000.00 $1,500.00 Operations $5,000.00 $20,000.00 $5,000.00 Supplies $4,125.00 $20,000.00 $7,000.00 Equipment $10,000.00 $6,000.00 Other: Food/snacks for youth & volunteers $5,000.00 $3,000.00 Other: Travel $5,000.00 Other: Gen'l Liability Insurance • $10,000.00 Other: Other: TOTAL $10,125.00 $175,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council 11=11 Staff appointed by a member of the Council N] The Mayor ❑� The Managing Director • The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 4./11 Signature of Authorized Person (specify title)"At/400W Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. (rt 2oW Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Daily attendance recorded to track number of youth exposed to program 75 youth Hours recorded to track time spent by volunteers for program implementation 2,520 hours Individual Student Success Plans used to track youth interests and goal setting Development ***See attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500.00 Professional Fees $1,500.00 Operations $5,000.00 Supplies $7,000.00 Equipment $6,000.00 Other: Food/snacks $3,000.00 Other: Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program -Attachment Fiscal Year 2021-22 Keaukaha One Youth Development (KOYD) Revealing Individual Strengths for Excellence (R.I.S.E.) Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I—Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Daily attendance recorded to track number Approximately 75 youth served of youth exposed to program 2) Hours recorded to track time spent by Approximately 2160 hours (see breakdown volunteers for program implementation: below): 60 hours per month x 12 months =720 hours Hours for Executive Director, Executive per person x 3 people= 2160 hours Assistant, and Fiscal/Administrative Coordinator Hours for volunteer mentors 10 volunteers, 360 hours (see breakdown below): 10 volunteers x 3 hours = 30 hours per month x 12 months = 360 hours 3) Individual Student Success Plans (ISSP) 100% youth begin development of ISSP and used to track youth interests and goal setting evidence of beginning stages of implementation such as goal setting and recorded support from mentors and parents Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries & Wages: Portion of Executive Director $2,500.00 Salary Administrative/Professional CPA— Year End Financial $1,500.00 Fees: Statement Generation Maintenance: Monthly Interior/Exterior $5,000.00 Grounds Maintenance Equipment Program/office supplies $7,000.00 Monthly 4G data plan + $2,000.00 portable wifi device for (2) RISE staff iPad's Xerox machine expenses $4,000.00 Food: Snacks/other food supplies $3,000.00 1 I(eaukaha One Youth Development Temple Children Collaboration Project 177 -u1 t, County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name:Temple Children Collaboration Project Agency Director: Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,s-r,zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑■ Hamakua ❑ North Kona ❑■ South Hilo ❑ North Kohala ❑ South Kona ❑■ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑� Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0.00 $0.00 $9,625.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD) is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities. Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The Temple Children Collaboration Project was designed to provide our youth with opportunities to participate in community revitalization efforts through enriching experiences involving art,food, and music. It will also allow for our youth to be involved in bridging these industries and the community as they share their cultural learning experiences with Temple Children's network of artists and project participants to foster a better understanding of place and how that contributes to their development as future leaders and the sustainability of our Hawaiian communities. 4.Total Budget & Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 TOTAL: Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Temple Children Collaboration Project continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Temple Children Collaboration Project will strive to reach the following objectives: 1) Provide opportunities to participate in community revitalization efforts through enriching experiences involving art, food, and music. 2)Strengthen youth interests in art and culture. 3) Promote collaborations that bridge the gap between the art industry and the community to contribute toward the sustainability of our island community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Event attendance recorded to track number of youth exposed to program 30 youth Hours recorded to track time spent by volunteers for program implementation 260 hours Community Mural&Beautification Events One event planned&completed ***See attachment Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees $5,000.00 $5,000.00 Operations Supplies $9,625.00 $8,000.00 $8,000.00 Equipment $5,000.00 $5,000.00 Other: Food/snacks for youth & volunteers $2,000.00 $2,000.00 Other: Travel $2,500.00 $2,500.00 Other: Other: Other: TOTAL $9,625.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I❑I Member or members of the Council ❑ Staff appointed by a member of the Council ❑I The Mayor 0 The Managing Director The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. cy(17a/t/' &Eon C pa9-eawy 112-4 202" Signature of Authorized Person (specify title) (I/V / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.Rov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. llrasi,ot, Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Event attendance recorded to track number of youth exposed to program 30 youth Hours recorded to track time spent by volunteers for program implementation 260 hours Community Mural & Beautification Events One event planned&completed ***See attachment TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages $2,500.00 Professional Fees $5,000.00 Operations Supplies $8,000.00 Equipment $5,000.00 Other: Food/snacks $2,000.00 Other: Travel $2,500.00 Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2021-22 Keaukaha One Youth Development (KOYD) Temple Children Collaboration Project Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Event attendance recorded to track number Approximately 30 youth of youth exposed to program 2)Hours recorded to track time spent by Approximately 260 hours (see breakdown volunteers for program implementation below): * One 2 hour community mural Hours for Executive Director, Fiscal implementation planning meeting per month x Administrative Coordinator, Two (2) Program 12 months = 24 hours x 4 volunteers = 96 Interns hours * 5 eight hour days to participate in community mural implementation x 4 volunteers = 160 hours 3) Community Mural & Beautification Events Completion of one community mural and beautification event at Palekai Reference to Page 4, Question 9: Table II—Program Expenditures Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Professional Fees: Artist Stipends $5,000.00 Equipment & Supplies: Various equipment and $13,000.00 supplies Other: Travel Costs $2,500.00 Snack/other food supplies $2,000.00 1 Keaukaha One Youth Development Youth Paddling Program 178 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Keaukaha One Youth Development Program Name:Youth Paddling Program Agency Director: Shadd Keahi Warfield Phone No.:(808 ) 895 —8666 Contact Person: Naomi Ahu Phone No.:(808 ) 756 —5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's Managment Groujp Phone No.:(808) 930 —6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street PO Box 4372 City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑� Hamakua ❑ North Kona ❑■ South Hilo ❑ North Kohala ❑South Kona ❑■ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑� Youth ❑Victims of Crimes ❑■ Culture and the arts ❑Aged ❑Victims of Health or Social Crises g Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $8,875.00 $13,500.00 $9,125.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities. Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2) instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hbkualaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The Youth Paddling Program was established in 2006 to offer Hawaii County youth ages 8-18 Native Hawaiian cultural opportunities that reconnect them to historic ocean experiences such as the Hawaiian canoe. 4.Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $470,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii(reflects current request) $25,000.00 TOTAL: Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: The Youth Paddling Program continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Youth Paddling Program will strive to reach the following objectives: 1)Teach the values of team work, goal setting, commitment, physical, mental, and spiritual well-being, and cultural identity through the use of the Hawaiian Canoe. 2)Utilize the Hawaiian Canoe to present the metaphoric message of ones journey through life: "you steer your own waa (life), but not without the help of others(KOYD and our extended communities)." 3) Help offset the high risks of drug and alcohol exposure/abuse among our Hawaii County youth through fostering after school canoe paddling practices and weekend regatta races, a healthier alternative for the utilization of their time. 4)Teach the values and processes necessary for the maintenance of Keaukaha Canoe Club's historic koa canoes and other equipment for current and future generations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How ore youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Daily attendance recorded to track number of youth exposed to program 120 youth Hours recorded to track time spent by volunteers for program implementation 850 hours OC1 and Regatta Events Participation of all qualified age groups ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees $500.00 $500.00 Operations Supplies $8,000.00 $12,500.00 $12,500.00 Equipment $1,125.00 $2,000.00 $2,000.00 Other: Travel $7,500.00 $7,500.00 Other: Other: Other: Other: TOTAL $9,125.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name:Youth Paddling Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council 10 The Mayor In The Managing Director Q The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■I If no conflicts exist, check here. 1/-\\-1 txEcan14-7 10-Eteg/ #2.5-10p2i Signature of Authorized Person (specify title) fyi ifr Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program i1. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Daily attendance recorded to track number of youth exposed to program 120 youth Hours recorded to track time spent by volunteers for program implementation 850 hours OC1 and Regatta Events Pa ticipation of eu qualified age groups ***See attachment TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,500.00 Professional Fees $500.00 Operations Supplies $12,500.00 Equipment $2,000.00 Other: Travel $7,500.00 Other: Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of Hawaii Non-Profit Grants Program —Attachment Fiscal Year 21-22 Keaukaha One Youth Development (KOYD) Youth Paddling Program Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the measurable performance outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Daily attendance recorded to track number Approximately 120 youth of youth exposed to program 2) Hours recorded to track time spent by Approximately 850 hours (see breakdown volunteers for program implementation below): * 16 two hour practices per month x 5 months Hours for Youth Division Head Coach, two (March-July) = 160 hours x 3 coaches =480 Youth Division Assistant Coaches, and one hours Youth Division Program Assistant * 9 ten hour Saturday regattas x 3 coaches = 270 hours * 20 hours per month for Program Assistant x 5 months = 100 hours 3) OC 1 and Regatta Events Participation of all qualified age groups and top rankings achieved Reference to Page 4, Question 9: Table II—Program Expenditures Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries & Wages: Portion of Executive Director $2,500.00 Salary Professional Fees: CPA- Year End Financial $500.00 Statement Generation Supplies: Paddle and canoe repair $5,500.00 Various paddling equipment $5,500.00 and supplies Escort boat repair and $1,500.00 maintenance Equipment: Portable toilet rental for $2,000.00 program site Other: Travel Costs (bus rentals, $7,500.00 gasoline expenses, airfare, etc.) 1 Koh ala Animal Relocation And Education Service (KARES) Accessible Veterinary Support for Family Pets 179 County of flawai'i Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets Agency Director: Deborah M. Cravatta, Pres. & Founder Phone No.:(808 ) 333 —6299 Contact Person: Deborah M. Cravatta Phone No.:(808 ) 333 —6299 Mailing Address: Address: Kohala Animal Relocation and Education Service (KARES) Address: P.O. Box 4460 city,sr,zip Kamuela, HI 96743 Facility Address: Address: Kohala Animal Relocation and Education Service (KARES) Address: 59-241 Kipa Mai Place City,ST,Zip Kamuela, HI 96743 Email Address: KARESHawaii@gmail.com Fax No.: (808 ) 880 —1925 Accountant/CPA: Marilyn J. Gagen Phone No.:(808) 220 —3087 Firm (if applicable): Marilyn J. Gagen, CPA LLC Mailing Address: Address: Marilyn J. Gagen, CPA LLC 6651 North Campbell Avenue #108 city,sr,zip Tucson, AZ 85718-1360 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds:.$68,000 Geographical Areas To Be Served: (One or more can be checked) n Puna 0 Hamakua © North Kona n South Hilo North Kohala ❑® South Kona n North Hilo I1 South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts n Aged ❑Victims of Health or Social Crises ❑® Needs of the poor n Physical/Emotional Disabilities ®❑ Public Health and Welfare of the People and the Environment • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 Flf 19-20 FY 20-21 $5,500 $11 ,668 $9,625 2. Agency Mission Statement: The widespread interest to create an organization adhering to a"no kill"philosophy gave birth to the Kohala Animal Relocation&Education Service(KARES)which serves the entire Big Island of Hawaii.The mission of KARES is to rescue and relocate abused,abandoned and stray domestic animals,to provide basic and rehabilitation medical care for rescued and owned pets,to provide temporary housing for them through our foster care network and to facilitate adoptions into caring permanent homes. - KARES focuses on community education to promote responsible pet ownership and to prevent animal cruelty. - KARES raises awareness about the causes of animal overpopulation and advocates alternative humane solutions for animal population control including spay and neuter procedures. - KARES emphasis is on reaching island residents who do not have the financial resources to provide accessible basic medical care and spay/neuter surgeries for their companion pets,especially the elderly,veterans,those in hospice and economically-troubled island residents. 3. Program Description: KARES program will focus on residents who do not have the financial resources to provide veterinary care for their companion pets, especially the elderly,economically-troubled and homeless individuals.Those having trouble feeding their families have little to no resources remaining to care for their beloved companion pets that bring them comfort in difficult times such as those the island is experiencing due to unemployment and COVID pandemic restrictions. KARES program is one of compassion to preserve the Hawaiian family that often includes one or more pets in a household. KARES is available 24/7: KARES will respond to appeals for medical/surgical pet care on a one-on-one basis as we have done for the past 11 years.KARES is widely known throughout the island and is often recognized as a last resort to help pets in need. In 2020 we placed 480 homeless pets in adoption homes and provided free spay and neuter(S/N)surgeries to 453 dogs.These 1,000 interactions with residents further spread the word through the island of our mission to help. Upon request,KARES will intervene to expedite emergency medical and/or surgical care for acutely ill or injured pets; potentially for up to 30 pets to be provided free.Basic veterinary care will be accessible for wounds, orthopedic repairs, tests and treatments for heartworm,dental care,skin conditions and tumors, eye issues, pain management,treatments for external and internal parasites. Healthy pets will be vaccinated. Provision of these services for at least 300 or more animals will directly benefit Hawai'i residents and improve the health status of their companion pets,which translates to improved general health of all island pets. KARES will offer free spay and neuter(S/N)surgeries for at least 300 pet dogs(25 dogs per month)of low income residents to control and reduce the overpopulation of dogs on the island. 4.Total Budget& Position Count: Total Program Budget: $120,000 Total Program Position Count: 10 Total Agency Budget: $135,000 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawa161 Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 5. Program Funding Sources(identify all sources of funding applied to this program): FV21-22 Revenue Source Estimate Grant applications submitted(or to be submitted)for review in 2021,or other sources of funding;provisional program income. Petco Foundation(pending 3.2021 announcement) $10.000 Grey Muzzle Organization-restricted to medical/dental assistance for senior dogs(submission planned for 3.2021) $9,000 County of Hawaii Non-Profit Grant (submission 1.2021) $10,000 Private(unsolicited)donations $30,000 TOTAL: $59,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As KARES animal welfare services have becomes more visible and requested over the years,we have documented increased numbers of first-time donors, both island residents and Mainland visitors,and private foundations; donations increased 52.6%in 2019 vs 2018,and up 50.3%in 2020 vs 2019.These anticipated yearly increased donation revenues will further support our programs. KARES continues to improve and expand our social media expertise and outreach(Facebook,etc.)with fresh, new weekly messaging and videos to highlight pet rescue efforts,and foster care to adoption;these efforts engage new and returning donors. KARES plans to use online funding campaigns to raise funds to assist pets with devastating and costly injuries;several"angel donations"in 2020 have allowed KARES to provide extraordinary care to help some pets with exceptional issues but also allowing KARES'to preserve financial resources for basic medical care for many more island residents'pets. KARES is always exploring new grant funding sources. In 2020 we received new funding from the Bissell Pet Foundation and Grey Muzzle Organization to help support our pet medical care program.A sustainable funding source for KARES is derived from pet adoption fees;our adoption numbers increase every year. KARES remained"essential"in 2020 with 480 cat&dog adoptions despite the COVID-19 closures.These monies will support our other programs. KARES objective is to provide free accessible medical/surgical care and free spay and neuter procedures to as many owned pets as possible depending on the availability of funding. Our dedication to this important work has no limitations; our volunteers are tireless. 7. Program Objectives Using County Nonprofit Grant Program Funds: KARES"Accessible Veterinary Support for Family Pets"will directly benefit the most vulnerable residents of Hawaii including those who are indigent due to generational and situational poverty,the elderly and veterans living on limited incomes,the homeless under the supervision of social service agencies and the unemployed due to the depressed island economy during the COVID pandemic and its aftermath. KARES program objectives are: 1) To provide free or financial assistance for acute and emergency medical care for pets of owners who are financially unable to do so;at least 30+families to be helped. 2)To facilitate and offer free veterinary care for at least 300 pets including basic medical,surgical,dental and wellness care(vaccinations,treatment for fleas, mites, intestinal worms,skin allergies; provide pain medications and antibiotics), 3)To provide free spay&neuter(S/N)surgeries for at least 300-330 companion dogs owned by indigent and elderly residents,an expense they cannot afford. 4)To respond to Hope Services requests to secure veterinary care and/or S/N of companion pets of homeless individuals. 5)To offer free transportation of pets to and from veterinary clinics for residents without vehicles or gas money;typically 75% of pets will need to be transported. by KARES volunteers. 6)To hire a coordinator for community outreach to identify,contact and coordinate veterinary care services and to provide pet transportation. KARES has no other paid staff only volunteers;our services are expanding greatly. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Please see page 4-A(Table 1) This online format will not allow fillable text large enough to read nor reflow to County Award Worksheet. Attach additional pages as necessary. 9.TABLE II: KARES 2020 FY FY 21-22 FY 21-22 PROGRAM EXPENDITURES Total Budget Grant Req `1-Dec 31`' g Salary and Wages : ?ra Am caorm',,lA v� 0 $28,000 $12,000 Professional Fees 0 $80,000 $80,000 $52,000 Operations Supplies $4,350 $2,000 0 Equipment ?walla/ �' ui�o�nonftJ? pi?3oscder $4,575 0 0 Other: Vaccines, anti-parasitics & deworming medications $5,000 $2,000 0 Other: Van expenses: animal transport & maintenance • $12,200 $8,000 $4,000 Other: ID Microchips; pet food for indigent pet owners $5,000 0 0 Other: Other: TOTAL $111,125 $120,000 $68,000 *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 8 Table I What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES Measurable Results* Families will not be forced to surrender,abandon or euthanize a beloved pet(s) Assist 30+serious medical/surgical cases for pets of low income because they cannot cover the costly veterinary fees for serious illnesses, families;follow-up on pet retention and health status. injuries or emergences. Health status of family pets will be improved by availability of FREE basic Serve 300 pets of low income residents; document number wellness and medical/surgical care. assisted. No delays or prevention of pet treatment will occur because of owners' lack of KARES volunteers to transport up to 300 pets for veterinary care. vehicles or money for gas. Provide FREE spay/neuter(S/N) procedures for dogs owned by economically- -Guarantee assistance for at least 300 families with one or more troubled residents and elderly people living on modest or fixed incomes; dogs. anticipate helping at least 300 residents. Many residents have more than one - Population control and reduction of number of owned dogs and dog to be S/N. subsequent feral dogs;prevent unwanted litters of puppies. -Reduce the number intakes and deaths by euthanasia of otherwise healthy dogs in public shelters,or those released into the wild or abandoned stray dogs that are unwanted, unadoptable or for whom there is no available safe,temporary shelter. Pets of homeless individuals owners will receive FREE basic vet care and spay& Document requests from Hope Services to assist 30+ pets. neuter(S/N) surgeries for their pets; requested by social service agencies Reduce damage to property, livestock& police nuisance reports caused by S/N = pet population control. intact stray&feral dogs. Review Animal Control data. KARES dedicates a minimum of 1,500 volunteer(unpaid) man-hours to 1,500+man-hours services provided by volunteers. outreach, organization of program transporting animals. Requested funding for new program coordinator will be only paid staff person. *Number assisted to be documented on Excel spreadsheets;comparative reviews to be made from County of Hawaii Animal Control data and intakes at public shelters(Hawaii Rainbow Rangers and Hawaii Island Humane Society). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4-A of 8 County of FIawai`i Nonprofit Grant Application FY2021 -22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets MIME toe ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: A/Dq. POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): Li Member or members of the Council Staff appointed by a member of the Council DI The Mayor 7 The Managing Director ■) The Director of Finance it The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Oygt/202 / Signature of Authorized Person (specify title) _ Date lasi#1,44, Remit/ 71 ke C4 OK' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of I Iawai'i Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible.Veterinary Support for Family Pets 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. odd/ 01/2/ c Signature of Authorized 'erson Date President and Founder Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Please see pages 8-A (Table 1) and 8-B (Table 2)for details This online format will not allowable fillable text large enough to read. TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $12,000 Professional Fees $52,000 Operations 0 Supplies 0 Equipment 0 Other: 0 Other: See details on Page 8-B Other: Other: $4,000 Other: TOTAL $68,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 .9i County of Nawar Nonprofit Grant Application Fll'2®21-22 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets gee COUNCIL AWARD WORKSHEET Table I: Applicant Council Proposed PROGRAM PERFORMANCE OUTCOMESApplicant Results Projected Result Families will not be forced to surrender,abandon or euthanize a beloved Assist 30+serious medical/surgical cases for pet(s)because they cannot cover the costly veterinary fees for serious pets of low income families;follow-up on illnesses,injuries or emergences. pet retention and health status. Health status of family pets will be improved by availability of FREE basic Serve document pets o low wr sncome residents; wellness and medical/surgical care. ted. No delays or prevention of pet treatment will occur because of owners' KARES volunteers to transport up to 300 lack of vehicles or money for gas. pets for veterinary care. Provide FREE spay/neuter(S/N)procedures for dogs owned by -Guarantee assistance for at least 300 economically-troubled residents and elderly people living on modest or families with one or more dogs. fixed incomes;anticipate helping at least 300 residents. Many residents -Population control and reduction of have more than one dog to be S/N. number of owned dogs and subsequent feral dogs;prevent unwanted litters of puppies. -Reduce the number intakes and deaths by euthanasia of otherwise healthy dogs in public shelters, Pets of homeless individuals owners will receive FREE basic vet care and Document requests from Hope Services to spay&neuter(S/N)surgeries for their pets;requested by social service assist 30+pets. agencies Reduce damage to property, livestock&police nuisance reports caused S/N=pet population control. by intact stray&feral dogs. Review Animal Control data. KARES dedicates a minimum of 1,500 volunteer(unpaid)man-hours to 1,500+man-hours services provided by outreach,organization of program transporting animals. volunteers. Requested funding for new program coordinator will be only paid staff person. *Number assisted to be documented on Excel spreadsheets;comparative reviews to be made from County of Hawaii Animal Control data and intakes at public shelters(Hawaii Rainbow Rangers and Hawaii Island Humane Society. EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8-A County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Accessible Veterinary Support for Family Pets 12. COUNCIL AWARD WORKSHEET Table PROGRAM EXPENDITURES FY 21-22 Grant Council Award Request Salary and Wages: Coordinator for community outreach to identify,contact and $12,000 coordinate veterinary care services and to provide pet transportation. Professional Fees:Veterinary fees $52,000 Operations: 0 Supplies: 0 Equipment: 0 Other: Vaccines, external parasites &deworming medications 0 Other: Van expenses: animal transport& maintenance $4,000 Other: ID Microchips; pet food for indigent pet owners 0 Total $68,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8-B Ku`ikallhi Mediation Center Community Conflict Prevention & Resolution Services 181 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ku'ikahi Mediation Center Program Name:Community Conflict Prevention & Resolution Services Agency Director: Julie Mitchell, Executive Director Phone No.:(808 ) 935 —7844 x 5 Contact Person: same Phone No.:( ) — Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: info@hawaiimediation.org Fax No.: (808 ) 961 —9727 Accountant/CPA: Bonnie Gibeault, CPA Phone No.:(808) 968 —1002 Firm (if applicable): Carbonaro CPAs & Management Group Mailing Address: Address: PO Box 4372 City,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑. Puna ❑® Hamakua ❑ North Kona ❑© South Hilo n North Kohala ❑ South Kona ] North Hilo n South Kohala DI Ka`0 Services or Activities To Be Provided: (One or more can be checked) O Educational concerns 0 Youth 0 Victims of Crimes ❑ Culture and the arts 'ill Aged ❑a Victims of Health or Social Crises 11 Needs of the poor ❑ Physical/Emotional Disabilities ®❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,750 $10,675 $11 ,250 2.Agency Mission Statement: OUR MISSION We empower people to come together--to talk and to listen,to explore options,and to find their own best solutions. To achieve this mission,we offer mediation,facilitation,and training to strengthen the ability of diverse individuals and groups to resolve interpersonal conflicts and community issues. OUR VISION A peaceful community where people routinely seek common ground. OUR VALUES Communication/Collaboration/Confidentiality/Courtesy/Competence OUR HISTORY Ku'ikahi is the sole nonprofit mediation center serving East Hawai'i and 1 of only 5 in the state. Our agency helps individuals,families,organizations,businesses,schools,and others to find creative solutions to challenging situations. Founded in 1983 as a program of the Island of Hawaii YMCA,and becoming an independent organization in 2006, Ku'ikahi has a 38 year track record providing mediation,facilitation,and training to further alternative dispute resolutions in the County of Hawai'i. Our purpose is"Finding Solutions,Growing Peace." 3. Program Description: In the area of mediation, mediated resolutions tend to be long lasting and help to improve relationships, promote understanding,and strengthen our community. Mediations are provided on an affordable sliding scale,with no one turned away for lack of funds. Between 50%to 60%of our mediation clients have annual household incomes of under$20,000. According to The Mediation Centers of Hawai'i"Economic Impact and Social Return on Investment Analysis for the Fiscal Year 2017,"for every$1 invested in these mediation programs,they deliver$8 in immediate and long-term consequential financial benefits to the citizens of Hawai'i. In May 2020,we launched the"Rapid Response Landlord Tenant Mediation Program"to provide free services to residential and commercial landlords and tenants during the COVID-19 crisis. In the areas of facilitation and training,we serve the public,private,and non-profit sectors. Unique opportunities include: 1) neutral facilitators for small and large groups,2) Free Brown Bag Lunch Series of monthly talks,3) public and private trainings in communication and transforming conflict,4)free in-house continuing education for volunteer mediators;and 5) peer mediation training for students. Due to COVID-19,we have pivoted to offering these programs mostly via Zoom. SUCCESS STORY:A landlord called our office, in despair. She was on a fixed income and depended on the(previously) reliable rental income from her long-time tenant. Rent had not been paid for many months due to COVID-19. The landlord completed an intake with our case manager,who then called the tenant. Mediation services and resources were offered to the tenant,along with reassurances that the landlord valued the tenant and wanted to keep them housed. The next week,the tenant attempted to get caught up on rent, and discussed directly with the landlord a clear plan for the future. By bridging the communication gap, our neutral third party helped both landlord and tenant to acknowledge these challenging times while expressing care to each other. Dignity, respect,and relationship were preserved for all. 4.Total Budget& Position Count: Total Program Budget: $282,695 Total Program Position Count: 4.50 Total Agency Budget: $315,195 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Direct contributions $45,089 Foundation/trust grants $66,000 United Way contributions $8,000 County of Hawaii nonprofit grant $25,000 Hawaii state&county contracts $51,169 Program fees(mediation,facilitation&workshops/trainings) $31,500 Cash reserves($18,125)+PPP loan forgiveness($34,912)+Other($2,900) $55,937 TOTAL: $282,695 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1)Offer 8 community workshops/trainings that are tuition based. Also,target market private,customized trainings for businesses and organizations. 2) Hold our 9th annual fund drive to solicit direct contributions, including from major donors(individuals and businesses). On our 990 from FY 2019-20,we reported$146,981 under"all other contributions,gifts,grants,and similar amounts." This amount is in addition to income from federated campaigns,fundraising events,government grants,and program service revenue. 3) Market our services to local businesses,schools/colleges, and community groups. This includes workplace mediation opportunities,facilitation of sensitive issues and sticky situations,and public and private workshops/trainings. 4) Research and apply for new and continuing grants from foundations, locally and nationally. We received$107,750 in FY 2019-20 and$86,450 n FY 2018-19 from foundations,as per our attached CPA audited financial statements. 5) Explore new partnership opportunities at the county and state levels for program and fund development. These may include applying for county and state RFPs,such as with County R&D, State Grants-in-Aid,etc. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide low-or no-cost mediation and facilitation services to self-,community-, and court-referred clients. Mediations are provided on an affordable sliding scale,with no one turned away for lack of funds. 2)Offer a critical alternative to litigation, especially for poor and indigent populations who cannot afford legal counsel and/or have a hard time navigating the legal system as unrepresented litigants. Local non-profit legal services and court self-help centers receive more inquiries than they can process. Mediation is integral to Hawai'i's"Access to Justice" framework,which strives to ensure that all people have access to civil processes. This is especially critical due to the anticipated tidal wave of court-referred eviction (summary possession)mediation cases once eviction moratoriums end. 3) Provide conflict prevention and resolution education to community members and volunteer mediators in East Hawai'i. Volunteer mediators may attend any educational program for free. Economically challenged community members may apply for scholarships to encourage attendance by diverse populations. Our educational programs have also attracted people/businesses from West Hawai'i, neighbor islands,and beyond. We serve all sectors:public, private,and non-profit. 4) Utilize 40+professionally trained volunteer mediators to provide primary service delivery. Annually,we offer Basic Mediation Training,from which we recruit volunteers to join a year-long apprenticeship program. Subsequently,these apprentices are graduated to mediator status and given continuing education to better serve the needs of the community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) #of mediation&facilitation cases opened 500 #of mediation&facilitation clients served(in cases closed) 1,000 #of mediation&facilitation sessions held 275 #of mediator volunteer hours donated 1,250 %of mediated cases that resulted in agreement 60% %of clients who felt mediation saved them time and/or money 70% %of clients who are satisfied with mediation 95% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $179,450 $186,315 $18,000 Professional Fees $19,000 $21,500 $4,000 Operations $69,000 $70,880 $2,000 Supplies $4,000 $4,000 $1,000 Equipment $1,000 Other: Other: Other: Other: PLEASE NOTE: FY 20-21 figures are estimates Other: since we are only 7 months into the FY TOTAL $272,450 $282,695 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 8.TABLE I (additional page): What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of free brown bag lunch talks held 12 #of brown bag lunch talk attendees served 360 of brown bag lunch talk attendees report learning something new& useful 95% #of trainings &workshops held 8 #of training&workshop attendees served 160 of training&workshop attendees report learning something new& useful 95% EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 (continued) County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): U Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑i The Managing Director If] The Director of Finance U The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ID If no conflicts exist, check here. e/LA b �, � January 28, 2021 ignat a of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 I County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 11. CertificM tion of Understa ndin (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 11. Certification .f Understan'ling (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. �.. January 28, 2021 S. nature of ! uthorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 12. C• l CIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result # of mediation &facilitation cases opened 500 # of mediation &facilitation clients served (in cases closed) 1,000 # of mediation &facilitation sessions held 275 # of mediator volunteer hours donated 1,250 % of mediated cases that resulted in agreement 60% % of clients who felt mediation saved them time and/or money 70% of clients who are satisfied with mediation 95% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $18,000 Professional Fees $4,000 Operations $2,000 Supplies $1,000 Equipment Other: Other: Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Kulkahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 12. C•UNCIL AWARD WORKSHEET TABLE I (additional page): PROGRAM PERFORMANCE MEASURES Applicant Council Projected Proposed Results Projected Result #of free brown bag lunch talks held 12 #of brown bag lunch talk attendees served 360 of brown bag lunch talk attendees report learning something new& useful 95% #of trainings&workshops held 8 #of training&workshop attendees served 160 of training&workshop attendees report learning something new& useful 95% EXHIBIT B NONPROFIT GRANT APPLICATION FY 2021'-2022 Page 8 of 8 (continued) Ku`ika hi Mediation Center Youth Peer Mediation Program 182 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Ku'ikahi Mediation Center Program Name:Youth Peer Mediation Program Agency Director: Julie Mitchell, Executive Director Phone No.:(808 ) 935 —7844 x 5 Contact Person: same Phone No.:( ) — Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: info@hawaiimediation.org Fax No.: (868 ) 961 —9727 Accountant/CPA: Bonnie Gibeault, CPA Phone No.: (gpg) 968 —1002 Firm (if applicable): Carbonaro CPAs & Management Group Mailing Address: Address: PO Box 4372 City,ST,Zip Hilo, HI 96720 YOU,493E RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) o Puna Hamakua North Kona ❑® South Hilo I I North Kohala Li South Kona �wiI North Hilo n South Kohala ®❑ Ka'Ci Services or Activities To Be Provided: (One or more can be checked) ®❑ Educational concerns ❑® Youth I I Victims of Crimes n Culture and the arts n Aged n Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $7,050 $8,513 $9,375 2.Agency Mission Statement: OUR MISSION We empower people to come together--to talk and to listen,to explore options,and to find their own best solutions. To achieve this mission,we offer mediation,facilitation,and training to strengthen the ability of diverse individuals and groups to resolve interpersonal conflicts and community issues. OUR VISION A peaceful community where people routinely seek common ground. OUR VALUES Communication/Collaboration/Confidentiality/Courtesy/Competence OUR HISTORY Ku'ikahi is the sole nonprofit mediation center serving East Hawaii and 1 of only 5 in the state. Our agency helps individuals,families,organizations,businesses,schools, and others to find creative solutions to challenging situations. Founded in 1983 as a program of the Island of Hawaii YMCA, and becoming an independent organization in 2006, Ku'ikahi has a 38 year track record providing mediation,facilitation,and training to further alternative dispute resolutions in the County of Hawai'i. Our purpose is"Finding Solutions, Growing Peace." 3. Program Description: In 2010,the Hawaii Department of Education(DOE)Safe Schools Community Advisory Committee established several recommendations to address conflict in the schools, including establishing a school community culture that creates and encourages an environment of safety and respect. To support this directive,we launched a youth peer mediation program in East Hawaii in 2015. Peer mediation is both a program and a process where students of the same age group facilitate resolving disputes between 2 or more people. Students in conflict can request mediation or be referred by staff or other students. Mediators work in pairs and help disputants reach and document agreements that are fair,safe,and doable. Peer mediation training focuses on the nature of conflict,communication and problem solving skills,and understanding and respecting differences. Through peer mediation and conflict resolution,students learn to work effectively with their schoolmates to facilitate positive outcomes. This process has proven effective in schools around the US and in Hawai'i. In the past 6 completed school years, Ku'ikahi's peer mediation program has reached 10 schools and trained 990 youth. Our 2021-22"Youth Peer Mediation Program"will focus on deepening the successful peer mediation programs at schools in the Ka'u-Kea'au-Puna(KPP)Complex Area and Hilo-Waiakea Complex Area, as well as seeking out new partners. We have developed curriculum to expand peer mediation into middle schools(piloted fall 2020 at Hilo Intermediate via Zoom). We also have created conflict resolution for kids trainings that are being offered at libraries,schools,and youth programs. PEER MEDIATOR QUOTE:"I have learned as a peer mediator to resolve conflict peacefully,to let both sides talk,and no picking sides. I have improved my communication and behavior because I don't fight as much and I don't yell at people as much. I am proud to be a peer mediator because I can resolve conflict and be peaceful." 4. Total Budget& Position Count: Total Program Budget: $32,500 Total Program Position Count: .50 Total Agency Budget: $315,195 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 5. Program Funding Sources (identify all sources of funding applied to this program): • FY21-22 Revenue Source Estimate Direct contributions $5,000 Foundation/trust grants $12,500 County of Hawaii nonprofit grant $15,000 TOTAL: $32,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) Research and apply for new and continuing grants from foundations, locally and nationally. To support peer mediation in FY 2020-21,we received funding from following foundations:Anderson-Beck Fund of the Hawai'i Community Foundation,Atherton Family Foundation, HEI Charitable Foundation,and Kukio Community Fund of the Hawaii Community Foundation. 2)Approach private donors,both individuals and businesses,to support the program. For example, KTA Super Stores renewed a 3 year pledge of$5,000 annually to support for peer mediation, most recently from 2019 to 2021;and Big Island Candies(BIC) has supported the program with$2,500 annually for 4 years from 2015 to 2019(on pause right now due to the COVID-19 economic downturn,though they still made a small gift in 2020). We will attempt to replicate this long-term program sponsorship for the upcoming fiscal year(s). BIC shared that, "It's a great idea to start at a young age." And KTA shared,"We look forward to a most successful[peer mediation]program because we also believe that early intervention is the best means of prevention." 3) Explore new partnership opportunities on the local and state levels for program and fund development. These include working with School Principals,Complex Area Superintendents, and Department of Education to cost-share the program in each school,plus consider applying for a State Grant-in-Aid. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Approximately 200 students will be trained as peer mediators(direct) and/or in conflict resolution for kids to serve approximately 1,400 students(indirect)from some of the most rural, disadvantaged areas of the state. Of the KKP Complex Area schools with which we've worked, between 91%and 100%of students are enrolled in free or reduced lunch, indicating high levels of need. In the 2016-2017 school year,"Schools in the Kau-Keaau-Pahoa Complex Area reported more than half of all Class A and Class B[misconduct]offenses islandwide last year. The complex area contained just under one-fourth of the island's public school student population." (Hawaii Tribune-Herald,7/24/2017). 2)At each school,hold the following activities: a.School year-start program planning and coordination (1 hour over 1 session), b. Faculty/staff conflict resolution training and/or peer mediation introductory presentation (.5 hour to 2 hours over 1 session)during first semester, c.Student peer mediation trainings(4 hours over 3 sessions per class)during first semester and follow-up trainings(1.25 hours over 1 session per class)during second semester,and d. School year-end student recognition events (1 hour over 1 session)during second semester. 3)Continue to expand peer mediation pilot into additional middle schools(in person or on Zoom)and offer conflict resolution for kids trainings at libraries,schools,and youth programs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) #of schools participating 4 #of youth trained in peer mediation&conflict resolution for kids 200 #of peer mediation&conflict resolution for kids trainings held 16 %of students who have changed the way they handle conflict in their own life 50% %of students and faculty/staff who felt peer mediation helped their school climate 60% %of youth trained who know how to help peers resolve conflicts at school year-end 75% %of faculty/staff who are satisfied with the program at school year-end 90% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES • FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $25,000 $26,500 $13,000 Professional Fees Operations $4,500 $5,000 $1,500 Supplies $500 $1,000 $500 Equipment Other: Other: Other: Other: PLEASE NOTE: FY 20-21 figures are estimates Other: since we are only 7 months into the FY TOTAL $30,000 $32,500 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): (❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor [El The Managing Director ❑ The Director of Finance In The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: D If no conflicts exist, check here. • k,.A.--- (, ueou b`r � January 28, 2021 ignatur f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of awai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 11. Certificatisn of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 28, 2021 Si nature of A horized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Havvai`i Nonprofit Grant Application FY2021-22 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 12. CU CILA EET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result # of schools participating 4 # of youth trained in peer mediation & conflict resolution for kids 200 # of peer mediation & conflict resolution for kids trainings held 16 % of students who have changed the way they handle conflict in their own life 50% %of students and faculty/staff who felt peer mediation helped their school climate 60% %of youth trained who know how to help peers resolve conflicts at school year-end 75% of faculty/staff who are satisfied with the program at school year-end 90% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $13,000 Professional Fees Operations $1,500 Supplies $500 Equipment Other: Other: Other: Other: Other: TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Kupu Hawaii Island Kupu ina Corps 2.0 183 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 Agency Director: John Leong Phone No.:(808 )735 —1221 Contact Person: Kawika Riley Phone No.:(808 )735 —1221 Mailing Address: Address: 677 Ala Moana Blvd, Suite 1200 Address: City,ST,zip Honolulu, HI 96813 Facility Address: Address: 677 Ala Moana Blvd, Suite 1200 Address: City,ST,Zip Honolulu, HI 96813 Email Address: kawika.riley@kupuhawaii.org Fax No.: ( ) — Accountant/CPA: Verity Certified Public Accountants Phone No.:(808 )546 —5026 Firm (if applicable):Verity Certified Public Accountants Mailing Address: Address: 1164 Bishop Street Suite 1001 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) • Puna ❑■ Hamakua ❑■ North Kona South Hilo 0 North Kohala 0 South Kona Q North Hilo El South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ['Victims of Crimes ❑ Culture and the arts ElAged ❑Victims of Health or Social Crises I Needs of the poor ❑ Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name: Hawaii Island Kupu ina Corps 2.0 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 N/A N/A N/A 2. Agency Mission Statement: To empower youth to serve their communities through character-building,service-learning,and environmental stewardship opportunities that encourage pono(integrity)with ke akua(god),self,and others. 3. Program Description: Introduction?Last year Kupu launched a statewide green jobs corps—the Kupu Aina Corps(KAC)--using CARES funds to employ and train over 360 displaced workers and recent grads in green collar jobs.With that experience behind us,we propose a Hawaii Island Kupu Aina Corps 2.0;a targeted program that provides urgent relief to unemployed residents while also adding to the county ' s economic diversification and Hawaii Island ' s role as a leader in carbon neutral economics. Background Information?Covid-19 has resulted in a severe global economic contraction,with the World Bank anticipating that internationally the economy will shrink by over 5 percent, amounting to the "deepest recession since the Second World War" .The U.S. has been more severe, and Hawaii has fared among the worst among the 50 states. Even more so,communities outside of Oahu have been hit particularly hard,with double-digit unemployment expected to continue throughout 2021. (See attached additional page for continuation of our Program Description) 4.Total Budget & Position Count: Total Program Budget: $2,350,000 Total Program Position Count: 40 Total Agency Budget: $9,190,754 Total Agency Position Count: 249 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Philanthropic partners $1,350,000 The Corps Network $ $520,000 TOTAL: $1,870,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Kupu has spoken with several prospective funders and identified likely federal partners.Weve currently identified $1,350,000 in potential funding from philanthropic partners.We also worked with the County of Hawaiis Governmental Operations, Relations and Economic Development Committee(GOREDC)to bring forward a resolution that will support the program in the coming years.We have proposed a multi-departmental collaboration that involves County of Hawai ' i Public Access, Open Space,and Natural Resources Preservation Commission(PONC)in partnership with the County of Hawaii Research and Development(R&D)department to assist with proposed management of the preserved open natural spaces and technical assistance with the RFP process for this program. In previous discussions, both departments have expressed interest in supporting the program. Kupu has also applied for$520,000 in grant funding from The Corps Network,a national association of service and conservation corps. If awarded,these funds would support climate change-related and community resilience related work, such as the work described in this application. Lastly,we have spoken with the County of Hawaii Research and Development(R&D)department to discuss a long-term relationship between the Hawaii Island Kupu Aina Corps 2.0 and the Kilauea Recovery Resiliency Plan.We envision a collaborative partnership that would bolster the outcomes and impacts of both programs and approaches. 7. Program Objectives Using County Nonprofit Grant Program Funds: Kupu seeks to continue the KAC beyond the conclusion of CARES Act funding in order to continue our triple bottom line approach of(1)economic relief; (2)diversification and resilience of our economy and (3)environmental stewardship. Our goal is to continue the program into a phase 2 stage, in which a relationship is struck between the County of Hawaii and Kupu Aina Corps so as to(1)develop a Hawaii Island Kupu Aina Corps 2.0;in order to(2)maintain Hawaii Islands preserved open natural spaces under the oversight of the County of Hawaii and (3)continue employment for recent alumni of Kupu Aina Corps from Hawaii Island beyond the end of CARES Act funding. In this vision, Hawaii Island Kupu Aina Corps 2.0 in partnershipwith the Countyof Hawaii will seed efforts for long-term, catalytic change for Hawaii Island.We 9 envision a minimum carbon neutral Hawaii Island achieved a through community-based network of carbon sequestration tY efforts using Hawaii Islands assets for this challenge,with hope for a carbon sequestration positive Hawaii Island. Host sites for Hawaii Island Kupu Aina Corps 2.0 members will be determined through a community-based process inviting proposals for the use of Hawaii Island Kupu Aina Corps 2.0 members for climate-related projects. Host sites will be evaluated based on criteria that considers multiple bottom line impact,demonstrated interest and capacity for long-term work beyond the length of the program,and willingness and capacity to provide on-the-job training for Hawaii Island Kupu Aina Corps 2.0 members in order to improve their job prospects within or outside of the host company after the end of the program.Those companies awarded Hawaii Island Kupu Aina Corps 2.0 members will receive them for up to 50 weeks, with the program paying for their hourly wage, health insurance and benefits,and access to Kupu conservation training. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participant work hours 80,000 hours Retention and completion rate in the program for participants 38 participants or 96% Estimated positive economic impact? $5,884,800 Ecological impact (see attached additional page) Post-program pathways (see attached additional page) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $1,543,950 $328,500 Professional Fees Operations $612,410 $130,300 Supplies $29,140 $6,200 Equipment Other: Administrative Fees $164,500 $35,000 Other: Other: Other: Other: TOTAL $2,350,000 $500,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): fl Member or members of the Council Staff appointed by a member of the Council O The Mayor QI The Managing Director 01 The Director of Finance El The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. John Leong, CEO of Kupu 1/28/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/28/2021 Signature of Authorized Person Date John Leong,CEO of KUpu Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Kupu Program Name:Hawaii Island Kupu ina Corps 2.0 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participant work hours? 80,000 hours Retention and completion rate in the program for participants 38 participants Estimated positive economic impact? $5,884,800 Ecological impact (see attached additional page) Post-program pathways (see attached additional page) TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $328,500 Professional Fees Operations $130,300 Supplies $6,200 Equipment Other: Administrative Fees $35,000 Other: Other: Other: Other: TOTAL $500,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 #3. Program Description (Additional Narrative) «.'EE'4:: U,..,,.v\.vT«'&,vm .&—,.ow'2.5t':a„%.:w"-.,—,,:,..',am—.,,,—ekYEfE??.. sa.M.a..: u btt. S.w.3 :...:. T......V.-,,,..amu.:.. ,�..'wa=, va Ec& .:.kut,i.. Al E,. .a,Wa.i.'.C.. to, ., Lt , F N r Eti"•,E . RETO -Rt. Introduction Last year Kupu launched a statewide green jobs corps --the Kupu `Aina Corps (KAC)-- using CARES funds to employ and train over 360 displaced workers and recent grads in green collar jobs. With that experience behind us, we propose a Hawaii Island Kupu `Aina Corps 2.0; a targeted program that provides urgent relief to unemployed residents while also adding to the county's economic diversification and Hawaii Island's role as a leader in carbon neutral economics. Background Information Covid-19 has resulted in a severe global economic contraction, with the World Bank anticipating that internationally the economy will shrink by over 5 percent, amounting to the "deepest recession since the Second World War". The U.S. has been more severe, and Hawai`i has fared among the worst among the 50 states. Even more so, communities outside of O`ahu have been hit particularly hard, with double-digit unemployment expected to continue throughout 2021. Alongside this economic and public health crisis, Hawaii continues to face a conservation deficit of several hundred million dollars annually. Sea level rise, decline in annual rainfall, and various indicators of ecological harm are cause for concern in Hawaii, nationally, and globally. These challenges call for solutions that can simultaneously do at least three things at once: provide immediate economic relief for struggling residents, improve Hawai`i's economic resilience through diversification, and care for the environment on which Hawai`i's people and economy depend. As an island that accounts for more than half of all of the state's total acreage, with community members already engaged in various climate change-related efforts, Hawaii Island is well positioned to lead the state in responding to this challenge in a way that can also further diversify its economy. Kupu has responded to this crisis in part by establishing the Kupu `Aina Corps (KAC), a state-wide green jobs program for people of all ages. In a few short months Kupu matched over 360 residents with jobs and training; over 90 percent of whom completed their program and employment term. At the end, over 1 in 3 participants report finding long-term employment, and their work produced over$6.5 million in economic benefit at less than half of that cost (in CARES funds). This also included caring for over 21,700 acres of land. With this experience bolstering us, we proposed a focused, longer-term green jobs corps for Hawaii Island. Hawaii Island Kupu `Aina Corps 2.0 would provide the same kind of training, experience, and employment as the 2020 version, and would use the same model of working in a network fashion and placing workers at Hawaii Island-based nonprofits, farms, and other green collar employers. It would be more targeted to climate change related positions, . resiliency-based professions, and other areas where Hawaii Island has particular promise as a host to industry. #8. Table I: Program Performance Outcomes (Additional Narrative) ,F494gfuo ,FP.too, gq PROGRAM PERFORMANCE OUTCOMES Ecological impact Invasive Animals Removed 3,430 animals Invasive Plants Removed 153,637 plants Engaged in Coastal Restoration 1,284 hours Trail Worked On 94 miles Stream Maintained 11,176 feet Acres impacted New Acres Treated (Managed)Total 9,553 acres Invasive Species Removed 9,188 acres Native Plants Planted 165 acres Debris Removed 93 acres Undefined 106 acres Post-program pathways Employment or Paid National Service after completion of the program 5 participants or 14% Starting or Resuming Higher Education after completion of the program 6 participants or 15% Candidates for Paid National Service Opportunities with Kupu after 4 participants or 11% completion of the program Total 15 participants or 40% #12. Table I: Council Award Worksheet (Additional Narrative) 747;qt410* t ; .4 3 PROGRAM PERFORMANCE OUTCOMES Application Projected Results Ecological impact Invasive Animals Removed 3,430 animals Invasive Plants Removed 153,637 plants Engaged in Coastal Restoration 1,284 hours Trail Worked On 94 miles Stream Maintained 11,176 feet Acres impacted New Acres Treated (Managed) Total 9,553 acres Invasive Species Removed 9,188 acres Native Plants Planted 165 acres Debris Removed 93 acres Undefined 106 acres Post-program pathways Employment or Paid National Service after completion of the program 5 participants or 14% Starting or Resuming Higher Education after completion of the program 6 participants or 15% Candidates for Paid National Service Opportunities with Kupu after 4 participants or 11% completion of the program Total 15 participants or 40% La'i'Opua 2020 Ho'okahua - Business Basics 184 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: La`i`opua 2020 • Program Name: Ho okahua--Business Basics Agency Director: Diana Akao Phone No.:(808 )327 —1221 Contact Person: Diana Akao Phone No.:(808)327 —1221 Mailing Address: Address: P.O. Box 1764 Address: • City,ST,ZIP Kailua Kona, HI 96745 Facility Address: Address: 74-5210 Keanalehu Drive Address: City,ST,Zip Kailua-Kona. HI 096740 Email Address: diana.kao@laiopua.org Fax No.: (808 )327 —1223 Accountant/CPA: Phone No.:(808) 242 —5002 Firm(if applicable): Carbonaro CPAs. Inc. Mailing Address: Address: 73-4976 Kamanu Street Suite 107 City,ST,Zip Kailua Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua 2 North Kona ❑South Hilo ❑North Kohala ❑South Kona ❑North Hilo 0 South Kohala ❑Ka`O Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑Youth 0 Victims of Crimes ❑ Culture and the arts 0 Aged 0 Victims of Health or Social Crises ❑ Needs of the poor ❑Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of M1» County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: La`i`opua 2020 Program Name: Ho`okahua—Business Basics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 • None None None 2.Agency Mission Statement: La`i`opua 2020 (L2020) was formed in 2006 by a group of community members from the surrounding area who wished to ensure a warm and welcoming center for all those transitioning into the surrounding Department of Hawaiian Homeland's Villages of La`i'opua as they were completed. La`i`opua 2020 received its 501(c) 3 not for profit status in 2007, and DHHL identified the La`i`opua Community Center Complex as a priority project in their Kealakehe/La`i`opua Regional Plan. L2020's planning process involved many community leaders, residents and service providers, and the plan grew into the vision of the center as pu'uhonua, as a place of healing, a wellspring; a place of safety to reflect and make right and transform to serve the self, the family, and the community. Its mission is "to provide social, recreational, vocational, economical, educational and cultural opportunities as well as infrastructure to the communities of the Kealakehe Ahupua`a.It is a place for pilin (building and supporting one another through relationships) and a pu'uhonua (a place of comfort, peace and safety)." La`i`opua 2020's recently constructed Community Center Complex (2019) includes the • Community Hale and a certified commercial kitchen. It is located in The Villages of La`i`opua, a master-planned Native Hawaiian community covering approximately 980 acres along the North Kona Coast of Hawai`i Island. It is just about in the center of North Kona and is a non- metropolitan Census tract which is considered Severely Distressed — Primary, as the median income is less than 80% of area median income (pre-COVID-19). It is also federally designated as a Native/Hawaiian Homelands Area and SBA designated as a HUB (Historically Underutilized Business)Zone. The L2020 Community Center Complex is bordered on the south by the West Hawai`i Community Health Center's Kealakehe Clinic and on the north by Kealakehe High School. The complex directly impacts La`i`opua Native Hawaiian Homestead households and residents as well as surrounding Kealakehe neighborhoods including 2,500 residents living in 336 public housing units adjacent to the Villages of La`i`opua. Hawai`i Public Housing Authority confirmed that at least 44% of these households had incomes under 50% of the average monthly income for the county of Hawaii prior to the COVID-19 crisis. Many of its residents work in the industries so negatively affected by the current loss of tourism due to the pandemic. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 10 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: La`i`opua 2020 Program Name: Ho'okahua—Business Basics 3. Program Description: opua 2020's Community Center Complex had literally just opened its doors when the pandemic struck, and the island's economy was literally shut down. When it became apparent that COVID-19 was on track to becoming a huge threat to the health, fmancial stability and food availability for our community, the La`i`opua 2020 board members held an emergency meeting to determine how L2020 could assist, and they decided to provide hot meals to the community through the use of the newly completed certified kitchen. Through a CARES ACT contract with Hawai`i County, La`i`opua 2020 created partnerships with local restaurants and distributed more than 50,000 hot,delicious meals to island residents between March 30 and November 30, 2020. While distributing the drive-through meals at the Kealakehe complex, L2020 staff and board had opportunities to check in with many of the surrounding residents and found there is great interest in the La`i`opua Business Incubator Project that had been planned, but cut short by the pandemic restrictions. To move forward on this plan, L2020 sought support for creating a safe learning environment at the complex. Both Kukio and the West Hawaii Funds of the Hawaii Community Foundation contributed to retrofit the Hale's large open space, designed to support workforce development,vocational training, continuing education and cultural education programs, so that it would meet all COVID-19 safety protocols recommended by both the State Department of Health and Hawaii County.L2020 has also outfitted this educational environment with a state-of–the-art technical infrastructure for use by program participants who may not have their own computer equipment or intereet accessibility at their homes for work and/or study purposes. With the infrastructure in place, L2020 is now ready to add another response to the challenges the pandemic has created for the population of West Hawai`i and begin its long-planned Business Incubator Project. The primary goal for L2020's Small Business Incubator Project is to support the creation of successful businesses which will in turn increase household income through net business income, improving the health and well-being of low and moderate-income residents of La`i`opua and the surrounding communities. L2020 will be able to do this by lowering barriers to entrepreneurship and supporting business profitability and growth through education, training, physical and financial resources. L2020's Ho`okahua—Business Basics program is a virtual and interactive adult peer-learning experience that will admit cohorts of 5 members each month for 11 months for a total of 55 participants over the year. During their one-month enrollment, cohort members will work and learn together starting with an orientation that gives them a chance to explore their own interests and abilities relevant to becoming an entrepreneur and starting their own business. They will also have the opportunity to meet and talk story with others in the community who have successfully made the transition from employee to"boss." EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 10 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: La`i`opua 2020 Program Name: Ho`okahua—Business Basics The subsequent three weeks will be spent completing L2020's Ho`okahua Business Basics curriculum by attending 2 classes per week for three weeks for a total of 6 classes. The curriculum includes: Business Incorporation; Business GET License; Bookkeeping, Quickbooks and Tax Planning; Marketing and Public Relations; Social Media; and Sales IT Skills. Knowledgeable business consultants will teach the classes, and all participants will be given their own copy of the Ho`okahua—Business Basics Handbook. At the conclusion of the curriculum, each cohort member will receive a Ho`okahua—Business Basics Certificate of Completion. These will be valuable to participants even if theyare notyet readyto take their businesspublic, P p as it will also be proof of workforce development and training for the resumes of those who wish to change their employment focus. L2020 Small The L2020 Ho`okahua—Business Basics Program is embedded in the glarger Business Incubator Project. While the Ho`okahua Program is open to anyone, no matter what business they have chosen to explore,it may be a gateway into the food industry for some through L2020's future Mobile Food Establishment(MFE)Pilot Project. 4.Total Budget&Position Count: Total Program t udget: $ 40.330.00 Total Program Position Count:. 1 Total Agency Budget: $140,680.00 Total Agency Position Count: 2 S. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Non Profit Grant $40,000.00 Program Fees $ 330.00 TOTAL: $40,330.00 Attach additional pages if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: The Ho`okahua Program is a program of the L2020 Small Business Incubator Project, as will be its future Mobile Food Establishment (MFE) Pilot Project that creates an opportunity for potential food entrepreneurs to explore the development of new food products and businesses. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 10 County of Hawaii Nonprofit Grant Application . FY2021-22 Agency Name: La`i`opua 2020 Program Name: Ho`okahua—Business Basics opua 2020 has submitted a grant proposal to the Department of Hawaiian Homelands (DIM) to support the Mobile Food Establishment Pilot Program for two years to begin May 2021. L2020 is also planning to submit a proposal to the USDA's Rural Development Agency to help agricultural producers and small rural businesses to develop new products from raw agricultural products or to promote new markets for established products. This will also become a program under the umbrella of L2020's Small Business Incubator. In Hawai`i, MFEs must have a certified or "support"kitchen to be DOH compliant. The MFEs are charged for the use of the kitchen and for storage. MFEs wanting to use the L2020 support kitchen may be charged from the time they begin use. These fees will then be used to support the Small Business Incubator Project. As the incubator graduates create jobs, revitalize their neighborhoods, commercialize critical new products and strengthen local economies, they will also help to sustain the L2020 Business Incubator Program for the future, including the Ho`okahua Business Basics Program. 7. Program Objectives Using County Nonprofit Grant Program Funds:. 1. The primary goal for L2020's Small Business Incubator Program is to produce successful businesses that will increase household income through net business income as a means of improving the health and well-being of low and moderate-income residents of La`i`opua and the surrounding communities. 2. L2020's Ho`okahua—Business Basics program will lower the barriers to entrepreneurship and support business profitability and growth through education, training, physical and financial resources. 3. Participants will learn in cohorts, building an environment that emphasizes collaboration and team building over competition. Classes will be presented by local business consultants, which will lend itself to the cultivation of work and personal networks that will continue long after the program ends. 4.At the completion of the Ho`okahua curriculum,participants will be prepared to actually start the business of their choice. 5. Those who complete the Ho`okahua curriculum, but who do not choose to start that business immediately will have acquired sufficient Workforce Development Training to expand their search for employment beyond the tourist industry. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 10 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lal'opua 2020 • Program Name: Ho`okahua—Business Basics PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe, be specific.) Participants have Certificates of Completion of Curriculum/Program 55 Participants Participants have completed 6 business start up classes 66 Classes Participants have what is needed to start their own business--license, 50 Participants registration, etc Participants have started a business within 6 months of completing the course. 30 Participants Participants have sought employment in industry other than tourism 25 Participants Attach additional pages as necessary. 5.TABLE H: PROGRAM FY 20-21 FY 21-22 FY 21-22 EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $18,560.00 $18,560.00 Professional Fees $9,880.00 $9,550.00 Operations $3,400.00 $E,400.00 Supplies $3,754.00 $3,754.00 Equipment Other:Printing $1,100.00 $1,100.00 Other:Admin Indirect $3,636.00 $3,636.00 TOTAL $40,330.00 $40,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 10 County of Ilawai'i Nonprofit Grant Application FY2021-22 Agency Name: La`i`opua 2020 Program Name: Ho'okahua—Business Basics 6. ORGANIZATION CONFLICT DISCLOSURE FORM • Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully.disclose.All disclosure forms must be signed,regardless of whether a conflict exists. NAME: Kawehi Inaba POSITION: President, La`i`opua 2020 May have a conflict or potential conflict of interest, including any familial,relationship, with any of the • following(check all that apply): ® Member or members of the Council n Staff appointed by a member of the Council fl The Mayor 111, The Managing Director fl The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict off Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: Kawehi Inaba is the President of the Board of Directors of La'i'opua 2020 and is related to District 8 County Councilman Holeka Inaba. He is her son. If no conflicts exist, check here. / • 21 . 2. t Signature of Authorized Person(specify title) Date President, Board of Directors Title EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 10 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: LaTopua 2020 Program Name: Ho'okahua—Business Basics 7. Certification of Understanding (Page l of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we)have the authority and ability to fully administer the program(s)pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. • If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s).To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 8 of 10 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: La'ibpua 2020 Program Name: Ho`okahua—Business Basics 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. , � / ( ' 7 . I Signature of Authorized Person Date President,Board of Directors /PJ1 (m lac,h/€ <%1 2 , Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 9 of 10 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: LaTopua 2020 Program Name: Ho`okahua—Business Basics 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants have Certificates of Completion of Curriculum/Program 55 Participants Participants have completed 6 business start up classes 66 Classes Participants have what is needed to start their own business--license, 50 Participants registration,etc Participants have started a business within 6 months of completing the course. 30 Participants Participants have sought employment in industry other than tourism 25 Participants TABLE II: • FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $ 18,560.00 Professional Fees $ 9,550.00 Operations $ 3,400,00 Supplies $ 3,754,00 Equipment Other: Printing $ 1,100.00 Other:10%Admin Indirect $ 3,636.00 TOTAL $ 40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION 'FY 2020-2021 Page 10 of 10 laupaloehoeTrain Museum 'Airia-Based Education Program for Youth and Community 185 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:'Aina-Based Education Program for Youth and Community , Agency Director:' Laupahoehoe Train Museum Phone No.:(808 ) 962 — 6300 Contact Person: Jennifer Bach Phone No.:(808 ) 640 — 0278 Mailing Address: Address: PO BOX 358 Address: City,ST,Zip Laupahoehoe, HI 96764 Facility Address: Address: 36-2377 Mamalahoa Hwy. Address: • City,ST,Zip Laupahoehoe, HI 96764 Email Address: dougconnors@yahoo.com Fax No.: ( ) • — Accountant/CPA: Natalie lwasa, CPA, Inc. Phone No.:(808 ) 395 —3233 'Firm (if applicable): Mailing Address: Address: 975 Kaluanui Rd • City,ST,Zip Honolulu, HI 96825 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 111 Puna Q Harnakua El North Kona • ['South Hilo 0 North Kohala Q South Kona ❑■ North Hilo n South Kohala . 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) • . 0 Educational concerns El Youth ❑Victims of Crimes • • n Culture and the arts ❑Aged C Victims of Health or Social Crises Q Needs of the poor ❑ Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment • EXHIBIT A 1 NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 • County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Laupahoehoe Train Museum Program Name: 'Aina-Based Education Program for Youth and Community 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 • 4,500 0 $7,375.00' 2. Agency Mission Statement: Laupahoehoe Train Museum (LTM)opened on March 1,1998 and celebrates the story of Hawaii's railroads, plantations, tsunami's, and the rich history of the Hamakua Coast. The museum projects and efforts invoke positive change in our rural community and is funded by donations, grants, memberships and volunteer commitment. The purpose of LTM is to preserve, promote and protect the historical, cultural, educational,social, civic, and economic interest of North Hilo and Hamakua districts while highlighting the history of the'railroads on the Island. The Honeybee Education Program(HEP),a program of LTM was created in 2009. HEP offers outreach programs to Hawaii Island's schools and island farmers. HEP's objective is to provide awareness and understanding about pollination as well as increase the number of beekeepers in the state of Hawai'i. In the past two years, HEP has educated and trained over 2,500 students and adults on the Island of Hawaii. In 2020, HEP collaborated on a community support project with Vibrant Hawai'i and Hawaii Rise Foundation to provide'Aina-Based Education to Resilience Hubs located on island. During the four month project, HEP provided over 320 hours of in person agriculture training to youth and adults. From this collaboration and project, HEP implemented a new program called'Aina-Based Education,which is in response to the recent pandemic tä support youth in providing hands-on programming for youth during after school hours or while children are not in school. 'Aina-Based Education programs serve all districts, linking Agriculture Instructors or educators to needed community groups in efforts to support food security and resiliency • '3. Program Description: Our project focuses on community-based solutions to preserving honeybees, pollinators,and our food supply on Hawai'i Island and is intended to benefit over 2000 youth, adults and farmers located in County of Hawai'i. This will include implementing an innovative education for youth and adults focused on'Aina-Based learning,food security and agriculture. The proposed will expand our programs reach to include opportunities for Hawai'i Island public schools to house bee hives on campus or nearby in efforts to train secondary students to become beekeepers or pursue agricultural careers. The new'Aina-Based Education,a program of the Honeybee Education Program,will work with children/youth at the 16 Resilience Hubs on island(a project in response to the covid-19 pandemic)to provide hands-on education, build community gardens and build food resiliency systems by providing agricultural training opportunities. HEP will provide free educational•enrichment programs,training programs and professional development opportunities that addresses a community need that is not currently being met. HEP has a strong base of support from beneficial partnerships,county and government organizations,and a large group of committed volunteers. This`project directly. benefits organic youth, Hawaii Island communities,agriculture,food security, honeybees, local pollinators and their habitats. • • 4. Total Budget & Position Count: • Total Program Budget: .$112,600 Total Program Position Count: 5 Tote q " gug , $ Total Agency Position Count: 2 EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • • • County of Hawai`i Nonprofit Grant Application FY202.1-22 Agency Name: Laupahoehoe Train Museum • 'Aina-Based Education Program for Youth and Community Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate • Laura Jane Musser Fund (secured) $ 10,000 Patagonia Food and Fiber Grant(secured) $ 8,000 Hawaii Community Foundation Career Connected Learning Grant(secured) $ 15,000 Hawaii Community Foundation Community Grant-Kukio Grant(secured) $ 10,000 . • Vibrant Hawaii Resilience Hub (secured) $ 25,000 In-kind Contribiutions(secured) $ 24,600 County of Hawaii Non-Profit Grant FY 2021-22. (pending) - $' 20,000 TOTAL: $ 112,600 • Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Honeybee Education Program has collaborated with all schools in Hawaii County. Working with schools allows our mission to be sustained as we hope to inspire and support the potential growth in the beekeeping industry byproviding educational services and vocational skills training that will ultimately expand the beekeeping community and sustain a ' healthy population of honeybees and local pollinators. The Hawai'i Beekeepers Association, Hawaii Farmers.Union and Tropical Fruit Growers Association also collaborates with•our organization in efforts to promote our services,link and bring farmers and beekeepers to our workshops, and create solutions towards sustainable agriculture in Hawai'i. Hawai'i Community College,Agriculture Department partners with the HEP in efforts to train Agriculture students in beekeeping. Partnerships include the Atherton Family Foundation, Laura Jane Musser Fund, East Hawaii Fund, Omidyar Ohana Fund, Western S.A.R.E, Hawai'i Community Foundation, Hawai'i Rise,Vibrant Hawai'i and Patagonia. These organizations have contributed financially to the HEP's mission and efforts If granted$20,000 from County of Hawai'i Nonprofit grant,the HEP will expand free outreach projects and implement agriculture and'Aina-Based Education throughout Hawai'i Island. If not all requested grant funding is received the balance will be solicited through future grants, community donations, benefits and in-kind services to the project or the project scope will have to be limited. • 7. Program Objectives Using County Nonprofit Grant Program Funds: Goals/Objectives: • 1.Youth will have access to a free outreach program through:in-class presentations,field trips to local apiaries& secondary beekeeping elective classes. Over 1800 students will benefit from this program objective.- 2.Youth will have access to'Aina-Based Education and enrichment programs located at resilience hubs on.Hawai'i Island. Programs include planting traditional crops and canoe plants,nutrition education, medicine provided by plants, creating' valued-added products,gardening and beekeeping 3. Four community gardens will be installed and mentorship will be provided by the HEP and newly formed'Aina-Based Education Program. We expect over 200 families will benefit from this program. • Our project focuses on a community-based solution to preserving honeybees, pollinators and our food supply in our rural communities.This includes implementing an innovating education geared for both adults and youth. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Laupahoehoe Train Museum Program Name:'Aina-Based Education Program for Youth and Community . .8.TABLE I: • What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES . (i.e.:How are youmeasuring what happens for the Participants after they have participated in your , program?Describe,be specific.) ' High School Elective Beekeeping Program (work with 2-4 schools per year) 100 secondary students Public School Presentations- 1 hour presentations to schools 1800 students per year 'Aina-Based Education offered to 16 Resilience Hubs located on Hawaii Island 320 youth/55 adults ____I Community Garden/Food Security Workshops to increase food security 200 adults ! Mentor and assist Community Garden implementation 4 sites/4 orginizations = : L Attach additional pages as necessary. • • 9. TABLE II: • r FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req ISalary and Wages 44,900 54,000 12,000 iProfessional Fees - . j ,Operations 4,000 2,000 1,500 I Supplies - 35,900 27,600 4,000_71 .Equipment 10,600 18,500 • :Other: Promotion 1,500 500_ 1 .Other: Administrative Cost 3,000 9,000 _2,000 - I Other: [Other: --I Other: ----a 1-- TOTAL $ 98,400 $ 112,600 ,$ 20,000. ) *If applicable • . • :EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 . County of Hawai`i Nonprofit Grant Application FY2021-22 , • Agency Name:Laupahoehoe Train Museum Program Name:'Aina-Based Education Program for Youth and Community 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii: Only those listed below need to be disclosed. One form per person with a conflict is needed: If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs,to be submitted. -Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether`a conflict exists. .NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): [01 Member or members of the Council In Staff appointed by a member of the Council n The Mayor in The Managing Director The Director of Finance • II The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: S • DI If no conflicts exist, check here: • • 1 /29/2021 Signature o Authorized Person (specify title) Date • EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2021-2022 • Page 5 of 8 County of Hawai`i Nonprofit Grant Application. FY2021-22 Agency Name:Laupahoehoe Train Museum .Program Name:'Aina-Based Education Program for Youth and Community w.... 11. Certification of Understanding (Page l•of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; • • and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority .to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. - I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. 1 (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I,(we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibilityto ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. . If awarded a grant from the County of Hawai'i, I (we) understand arid will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, •go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. • If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Ilawai`i Nonprofit Grant Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:'Aina-Based Education Program for Youth and Community ' 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit_grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aqency's future fundinq request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction,materials, insurance or securities) on private properties unless otherwise authorized by law. Uy signing below, you are acknowledging that you have read and understood these requirements. 1 /29/2021 Signature f Authorized Person Date • Treasurer Title/Position of Authorized Person EXHIBIT A S 'NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 • Agency Name: Laupahoehoe Train Museum Program Name:'Aina-Based Education Program for Youth and Community 12. COUNCIL AWARD WORKSHEET TABLE I: . Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result High School Elective Beekeeping Program(work with 2-4 schools per year) 100 secondary , Public School Presentations-1 hour presentations to schools 1800 students per `Aina-Based Education,offered to 16 Resilience Hubs located on Hawaii Island 320 youth/55 adults Community Garden/Food Security Workshops to increase food security 200 adults • Mentor and assist Community Garden implementation4 sites/4 orginizations J TABLE II: - . FY 21-22 Council PROGRAM EXPENDITURES • Grant Request Award Salary and Wages $ 12;000 Professional Fees • Operations $ 1,500 • - _ Supplies $ 4,000 ..___ Equipment ' • • 1' Other: Promotion $ 500 I1 . Other: Administrative Cost $ 2,000 Other: . Other: . Other: _ .TOTAL $ 20,000' 'Additional Council directives regarding award:. • EXHIBIT B • - • NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8-of 8 Laupahoehoe Train Museum The Honeybee Education Program 186 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:The Honeybee Education Program: Professional Development Agency Director: Laupahoehoe Train Museum Phone No.:(808 )962 — 6300 Contact Person: Jennifer Bach Phone No.:(808 )640 - 0278 Mailing Address: Address: PO BOX 358 Address: City,ST,Zip Laupahoehoe, HI 96764 Facility Address: Address: 36-2377 Mamalahoa Hwy. Address: City,ST,Zip Laupahoehoe,HI 96764 Email Address: dougconnors@yahoo.com Fax No.: ( ) — Accountant/CPA: Natalie Iwasa, CPA, Inc. Phone No.:(808 ) 395 —3233 Firm (if applicable): • Mailing Address: Address: 975 Kaluanui Rd City,ST,Zip Honolulu,HI 96825 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna 0 Hamakua North Kona Q South Hilo 0 North Kohala 0 South Kona • 0 North Hilo 0 South Kohala 0 Kali Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth ❑Victims of Crimes • 0 Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor 0 Physical/Emotional Disabilities CI Public Health and Welfare of the People and the Environment EXHIBIT A • County `of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Laupahoehoe Train Museum Program Name:The Honeybee Education Program: Professional Development 1. Prior Year Award of County Nonprofit Grant Program Funds: FY18-19 FY19-20 FY20-21 • 4,500 0 $7,375.00 • 2.Agency Mission Statement: Laupahoehoe Train Museum(LTM)opened on March 1,1998,and celebrates the story of Hawai'i's railroads,plantations, tsunami's,and the rich history of the Hamakua Coast. The museum projects and efforts invoke positive change in our rural community and is funded by donations,grants,memberships and volunteer commitment. The purpose of LTM is to preserve, promote and protect the historical,cultural,educational,social,civic,and economic interest of North Hilo and Hamakua districts while highlighting the history of the railroads on the Island The Honeybee Education Program(HEP),a program of the LTM was created in 2009. HEP provides outreach programs to Hawai'i Island's schools and farmers. HEP's objective is to provide awareness and understanding about pollination as well as increase the number of beekeepers in the state of Hawai'i. In the past two years, HEP has educated and trained over 2,500 students and adults on the Island of Hawai'i. The HEP provides programming for youth,training and professional development services for adults and bridges networks of resources and training opportunities to farmers and producers. Working with nonprofits,government agencies and community-based groups has allowed us to support more than just beekeepers as we broaden our reach to support Hawai'i County food producers and farmers. A major goal our project is to build and support food resilience systems and security in Hawaii. 3. Program Description: • Our project focuses on community-based solutions to preserving honeybees,pollinators,and our food supply on Hawai'i Island and is intended to benefit over 200 adults and farmers located in County of Hawai'i during the 21/22 fiscal year. This will include implementing two training/technical assistance programs that ultimately support food security and agriculture in Hawai'i:Two Beginning Beekeeping Workshops and Seven Advanced Beekeeping Workshops/Training Courses Honeybee Education Program provides free educational enrichment programs,training programs and professional development opportunities that addresses a community need that is not currently being met, The HEP has a strong base of support from beneficial partnerships, county and government organizations,and a large group of committed volunteers. This project directly benefits Hawaii Island communities,agriculture,food security,honeybees,local pollinators and their habitats. 4.Total Budget& Position Count: • Total Program Budget: $ 23,000 Total Program Position Count: 5 ifo ol•AgenlotBudgeui;-4175,0Q6,y., Total Agency Position Count: 2 EXHIBIT A County of flawai`i Nonprofit 6Trant Application FY2021-22 Agency Name: Laupahoehoe Train Museum • The Honeybee Education Program: Professional Development Pro_ram Name: • 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 ' Revenue Source Estimate Laura Jane Musser Fund (secured) $ 4,000 Vibrant Hawai'i Resilience Hub (secured) $ 5,000 In-kind Contribiutions(secured) $ 4,000 County of Hawai'i Non-Profit Grant FY 2021-22. (pending) $ 10,000 TOTAL: $ 23,000 • Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Honeybee Education Program has collaborated with all schools in Hawaii County. Working with schools allows our mission to be sustained as we hope to inspire and support the potential growth and advancement in the beekeeping industry by providing educational services and vocational skills training that will ultimately expand the beekeeping community and sustain a healthy population of honeybees and local pollinators. The Hawai'i Beekeepers Association, Hawai'i Farmers Union and Tropical Fruit Growers Association also collaborates with our organization in efforts to promote our services,link and bring farmers and beekeepers to our workshops,and create solutions towards sustainable agriculture in Hawai'i. Hawai'i Community College,Agriculture Department partners with the HEP in efforts to train Agriculture students in beekeeping. ' Partnerships include the Atherton Family Foundation,Laura Jane Musser Fund, East Hawaii Fund,Omidyar Ohana Fund, Western S.A.R.E, Hawaii Community Foundation,County of Hawai'i,Hawai'i Rise,Vibrant Hawai'i and Patagonia. These organizations have contributed financially to the HEP's mission and efforts. If granted$10,000 from County of Hawai'i Nonprofit grant,the HEP will expand free professional development services for local farmers, beekeepers and residents throughout Hawaii Island. If not all requested grant funding is received the balance will be solicited through future grants,community donations,benefits and in-kind services to the project or the project scope will have to be limited. 7. Program Objectives Using County Nonprofit Grant Program Funds: Professional Development Opportunities for Hawai'i's Beekeepers Program: Beginning beekeeping program: We estimate to offer two free 30-hour workshops to train 30-40 Hawaii Island farmers. Workshops are geared to change behavior and attitudes of community and farmers. We anticipate 80%of participants will incorporate bees on their farms or homestead. Advanced beekeeping program:Specialized instructors,will provide training workshops needed to equip beekeepers with needed training to advance beekeeping in Hawaii.Seven 2-hour workshops to train up to 40 participants on advance beekeeping.maintenance,techniques,and training to assist with honeybee declines and pest issues. Workshops are geared to answer specific needs of local farmers and beekeepers. We anticipate that these workshops will increase beekeeper success and beehive longevity by 60%. Evaluations will be provided for all participants(pre and post surveys). YouTube videos will be recorded and shared publicly to broadcast information. Additional evaluations will be sent to participants at six months and one year after workshop. EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:The Honeybee Education Program: Professional Development 8.TABLE I: • What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 'Beginning Beekeeping Workshops(two 4-week workshops) 30-40 Hawaii Island.Farmers Advance Beekeeping Workshops/Professional Development for experienced beekeepers 7 workshops to serve 40 beekeepers Workshops wffi be posted oo6naMrtually to share with local tanners who cannot attend in-person workshops 100 participants Attach additional pages as necessary. 9.TABLE 11: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 6,000 7,000 4,500 Professional Fees Operations 2,100 4,000 1,500 Supplies 3,900 5,500 4,000 Equipment • 4,900 6,500 Other: Other: Other: Other: Other: TOTAL $ 16,900 $ 23,000 $ 10,000 *If applicable • • • EXHIBIT'A County of Hawaii Nonprofit Grant Application FY2021-22 ' Agency Name:Laupahoehoe Train Museum Program Name:The Honeybee Education Prograrri Professional Development 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: • May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): f Member or members of the Council , Staff appointed by a member of the Council' fl The Mayor 13 The Managing Director • fl The Director of Finance fl The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • • If no conflicts exist,check here. 1/29/2021 ' Signature o Authorized Person (specify title) Date EXHIBITA • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:The Honeybee EduoatIon Prp ram: Professional Development 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- •135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority • to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that informationsupplied herein,'including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. • I (we) understand that all documents requiring a current signature must be the ORIGINAL SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. • If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go toi`t'n:/=`ve:dors.ehat , complete the easy step-by-step process, and pay the annual registration fee online using a credit card. • If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding.requests. EXHIBITA • County of]Hawai`i Nonprofit.:t rat :Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:The Honeybee Education.Progiam: Professional Development 11.Certificatlkh1'de tial di17g (Page 2 of 2) If awarded a grant from the County of Hawai'i, I,(we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each‘occ rrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. 'I (we) understand there is no provision for further notification to submit the final report. Information eq h ,i �:..; -. _ r `�' ` �c� s� on pr about and instructions are available at -t�c_. r �:� 4r� -}. _ May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/29/2021 Signature of/Authorized Person Date Treasurer Title/Position of Authorized Person EXHIBIT A County of Hawai 1 Non tia ii Cidnt Application FY2021-22 Agency Name:Laupahoehoe Train Museum Program Name:The Honeybee Education Program: Professional Development 12. COUNCILAIARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result • Beginning Beekeeping Workshops(two 4-week workshops) 30-40 farmers Advance Beekeeping Woricshops/Professional Development for experienced beekeepers 40 beekeepers Workshops will be posted ordineMQhratlY to share with Local tanners who cannot attend unperson warlcsI OPs 100 participants TABLE II: FY 2122 Council PROGRAM EXPENDITURES Grant Request Award ° Salary and Wages $ 4,500 Professional Fees • Operations • -$ 1,500 Supplies $ 4,000 Equipment Other: Other: Other: Other: Other: TOTAL $ 10,000 Additional Council directives regarding award: EXHIBIT B Little Big Tots Foundation Scholarship Awards 187 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Little Big Tots Foundation Program Name:Scholarship Awards Agency Director: Kristina Tolentino - Phone No.:(808 )796 —1106 Contact Person: Kristina Tolentino _. Phone No.:(808 )796 —1106 Mailing Address: Address: Po Box 641 Address: City,ST,zip Hilo, HI 96721 Facility Address: Address: Address: City,ST,Zip Email Address: admin@littlebigtots.org Fax No.: ( ) — Accountant/CPA: Laimana Wong Phone No.:(808 ) 936 -4544 Firm (if applicable): Mailing Address: Address: 281 Lyman Avenue city,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua ❑■ North Kona 0 South Hilo Q North Kohala 0 South Kona 0 North Hilo Q South Kohala 0 Ka'u Services or Activities To Be Provided: (One-or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY 2021-22 Agency Name: Little Big Tots Foundation Program Name: Scholarship Awards 1. Prior Year Award of County Nonprofit Grant Program Funds: FY18-19 FY19-20 FY20-21 None None $11,250 2. Agency Mission Statement: To provide financial assistanct to the youth members of the communities ages three (3)to thirteen (13)years of age to increase participation in extra-curricular activities in the State of Hawaii. 3. Program Description: The 2020-2021 Fiscal Year was a time of experience for Little Big Tots Foundation. It was the official first year of operating the Scholarship Awards Program.The program struggled due to Covid-19 but was successful in reaching numerous eligible youths. Many activities temporary ceased their seasons until further notice and therefore caused minor challenges for the Fouhdation.The program was able to support extra-curricular activities such as Kamaaina Kids, Baseball, and Swimming. Little Big Tots foundation seeks to service a minimum of one-hundred twenty-five youth with the upcoming fiscal year.The programs timeline to reach every child of the Island of Hawaii has been pushed back due to the challenging times but will not discourage the foundations mission to increase the numbers of youth participants. As times have changed, the program adjusted to meet the needs of the recipients.The program will award monetary or merchandise scholarship awards to put towards registration fees or supplies and equipment.An extra-curricular activity that requires the child to purchase supplies or equipment may apply to cover the costs.Applicants will only be allowed to apply for either a monetary or merchandise award.This will help grant more children the opportunity to receive an award. The process will remain the same with minor changes to enhance the program ' s success.All applicants will complete a simple application with Little Big Tots Foundation either online or with a paper application. The application will then be reviewed and verified for eligibility and reported to the Board of Directors for approval. To qualify a child must be registered or be currently enrolled in an eligible activity, live on the Island of Hawaii and are between the ages of three(3) to thirteen(13)years old.The program will help increase the participation of Hawaii's youth in activities that will help enhance, engage, and increase their life experiences. Beginning FY 2021-2022, Little Big Tots Foundation will implement the following changes for the upcoming program: 1) 4. Total Budget & Position Count: Total Program Budget: $40,000 Total Program Position Count: 125 Total Agency Budget: $50,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 - - Agency Name: Little Big Tots Foundation Program Name: Scholarship Awards 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Government Grants $25,000 Private Foundation Grants $10,000 Fundraisers/Private Donations. $5,000 TOTAL: $40,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The foundation is seeking increased grant funding from various private donars and foundations to allow operation of the program to continue to be successful. Fundraisers are also a continued source of funding for the Foundation even through the challenging times. 7. Program Objectives Using County Nonprofit Grant Program Funds: The main objective of the program is to increase the number of youth participants in an extra-curricular activity in the State of Hawaii. Allowing the youth to be engaged thru this challenging times will help children continue to have a social life as well as gain life skills and experiences. Little Big Tots Foundation seeks to develop future leaders of the State of Hawaii and provide them opportunities to grow by assisting in the finanical aspect of families hardships. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Little Big Tots Foundation Program Name: Scholarship Awards 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Program Enrollment Numbers Amount of Scholarships awarded Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $8,000 $5,000 Professional Fees Operations $2500 $1000 Supplies $2500 $1000 Equipment $2000 $1000 Other: Scholarship Awards $25,000 $12,000 Other: Other: Other: Other: TOTAL $40,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Little Big Tots Foundation Program Name:Scholarship Awards 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑] The Director of Finance [O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. c\(..eprONQi 1/11/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Little Big Tots Foundation Program. Name:Scholarship Awards 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.Rov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit-Grant Application FY2021-22 Agency Name:Little Big Tots Foundation Program Name:Scholarship Awards 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 4Q-D 1/11/2021 Signature of Authorized Person. Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Little Big Tots Foundation Program Name:Scholarship Awards 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Program Enrollment Numbers 125 Amount of Scholarships Awarded 125 TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages $5000 Professional Fees Operations $1000 Supplies $1000 Equipment $1000 Other: Scholarship Awards $12,000 Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Lokahl Treatment Centers, Inc Adolescent Substance Abuse Treatment Programs 188 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Lokahi Treatment Centers, Inc. Program Name:Adolescent Substance Abuse Treatment Programs Agency Director: Jamal F. Wasan, Ph.D. Phone No.:(808 ) 883 —0922 Contact Person: Cory Causey Phone No.:(808) 969 —9292 Mailing Address: Address: P.O. Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate) 68-1845 Waikoloa Road, Ste. 224 B Address: City,ST,Zip Waikoloa, HI 96738 Email Address: ccausey@lokahitreatmentcenters.net Fax No.: (808 ) 969 —7337 Accountant/CPA: Hanako K Anderson Phone No.:( ) — Firm (if applicable): Mailing Address: Address: P.O. Box 1514 City,ST,Zip Kapaau, Hawaii 96755 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) © Puna Q Hamakua 0 North Kona ❑■ South Hilo North Kohala 0 South Kona O North Hilo 0 South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns g Youth 0 Victims of Crimes 0 Culture and the arts ❑ Aged 0 Victims of Health or Social Crises ❑■ Needs of the poor 0 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,953 $11 ,055 $13,500 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional, cognitive, and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs; and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referrals to other community-based resources for continued recovery. *We believe in a non judgmental approach with compassion, respect and dignity for all. 3. Program Description: Lokahi Treatment Centers(LTC)Adolescent Substance Abuse Programs provide comprehensive treatment services for adolescents(aged 10-18)at all five(5)office locations throughout Hawai'i Island.Treatment services are for individuals that complete a substance use assessment and through this detailed assessment are determined to be in need of treatment services that includes the provision of education to abstain from the use of substances,the development of relapse prevention skills and a treatment plan, individual counseling to address other problematic factors,and case management services. LTC's continuum of care(levels of care)includes: Intensive Outpatient, Outpatient, Continuing/After Care,and Prevention Programs. A majority of adolescent clients are referred for substance treatment services from Juvenile Probation or Teen Court. Schools are also referring students who are in need of treatment. LTC's adolescent substance abuse treatment programs are integrated to include mental health services,to address co-occurring disorders that are impacting their recovery process. LTC's adolescent substance treatment program utilizes evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities(CARF)standards.Evidence-based curriculum's are consistently updated to include well-developed strategy models that are proven effective by behavioral health care treatment accreditation facilities throughout the nation.These curriculum's include the inclusion of family members and other supportive individuals;through these individuals, adolescents become well adjusted and develop the ability to create healthy long-term relationships that aide in relapse prevention, criminal thinking and behaviors, and a reduction in trauma-induced mental illness factors. 4.Total Budget& Position Count: Total Program Budget: $170,000 Total Program Position Count: 6 Total Agency Budget: 1,425,500 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Managed Care(Third Party Insurance) 135,000 County of Hawaii,Nonprofit Grant Contract 35,000 TOTAL: 170,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Before the COVID-19 pandemic,we were in the process of negotiating rates with managed care providers,i.e., HMSA, UHA, etc.and requesting to develop incentive programs for Lokahi Treatment Centers to provide enhanced out-patient treatment services targeting opioid use and suicide prevention for our youth. LTC would also include the consequences of drug use in teenage pregnancies. Opioid use during pregnancy can result in a drug withdrawal syndrome in newborns called neonatal abstinence syndrome, or neonatal opioid withdrawal syndrome(NAS/NOWS), which cases costly hospital stays. An analysis by the National Institute of Drug Abuse(NIDA)showed that an estimated 32,000 babies were born with this syndrome in the United States in 2014,which was more than a 5-fold increase since 2004. NIDA concluded that every 15 minutes,a baby is born suffering from opioid withdrawal.A January 2019 report from NIDA stated that every day,more than 130 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids,including prescription pain relievers, heroin, and synthetic opioids such as fentanyl,is a serious public health crisis here in Hawai'i County that affects our social and economic welfare.It has devastating consequences. We continue to see an increase of clients,including adolescents who have used or still using opioids. This grant will help us to maintain the increasing number of participants,while we negotiate payment rates and incentive programs with managed-care providers, We will also continue to recruit volunteers for creative fundraising activities during abnormal times. LTC is committed to meet the multiple needs of the population we serve even if it is more costly to provide these services within the CDC guidelines and State and County restrictions. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to treatment services to any adolescent that is assessed and diagnosed with any substance use disorder.Treatment services will also include mental health and other behavioral treatment that may be deemed necessary for long-term recovery and to maintain sobriety. 2. Provide enhanced out-patient treatment services targeting mental health,opioid use and suicide prevention for adolescents. 3. Focus heavily on issues related to self-perception and self-esteem in an effort to improve both and to build the self-confidence and self-efficacy that make attempts to abstain from drugs and alcohol more successful. We were in the middle of a mental health crisis before COVID-19 hit with suicide becoming more prevalent than ever. The effects of online schooling,social distancing(not the norm for our culture), lock-down,losing loved ones and even the over-consumption of media reports are taking a toll on our adolescent's mental health and their wellbeing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 8.TABLE I: • What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Increase#of adolescents who remain abstinent from opioids,alcohol;and other stimulants Increase by 25% Increase#of adolescents who remain in treatment for full course of recommended services Increase by 25% Increase#of adolescent social supports during treatment&at time of discharge Increase by 25% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $100,000 $35,000 Professional Fees $25,000 Operations $25,000 Supplies $15,000 Equipment $5,000 Other: Other: Other: Other: Other: TOTAL $170,000 $35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 "How are you measuring what happens for the participants after they have participated in your program?" Lokahi Treatment Centers (LTC) TheraScribe Program is used for Assessments, Treatment Planning and Case Management. It is customized for each specific client and will track the progress of each client. LTC creates treatment plans with predetermined problems, definitions, goals, objectives, interventions, and a diagnosis. LTC also includes homework assignments in each of the individual treatment plans. Lokahi Treatment Centers (LTC) identifies the baseline measures to document changes of the treatment program for each client. LTC collects metrics at regular intervals to monitor the effectiveness of the intervention. The measures used to evaluate the program may vary depending on the program model used and the goal of the evaluation, which include demographic information, process measures, and outcome measures. LTC also utilizes three other evaluation instruments to ensure quality of our service delivery; the quality of life inventory (QOLI) which is a brief assessment of 32-items that provide life satisfaction outcomes in a scoring format on 16 areas; health, self-esteem, goals/values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, and community. This instrument will be given at the beginning of treatment upon completion of the first 90-days and at the time of full clinical discharge. It is extremely useful in mapping the clients' progression from dysfunctional patterns in the quality of their life and how they shift throughout treatment. The second instrument is a New Direction Survey which is used for pre and post treatment that is completed by both the client and clinical staff. The third is a likert scale client satisfaction survey given to all clients monthly. County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs toe ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Di If no conflicts exist, check here. 'r-6lei vif r / 2 6 21 nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name:Adolescent Substance Abuse Treatment Programs 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs is. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawallc.:,3niy.g,ov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. _ _ . / 26 2 / Signature of Authorized Person Date PrVirreil#04/666 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase#of adolescents who remain abstinent from opioids,alcohol, and other stimulants Increase by 25% Increase#of adolescents who remain in treatment for full course of recommended services Increase by 25% Increase#of adolescent social supports during treatment&at time of discharge Increase by 25% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $35,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Lokahi Treatment Centers, Inc Adult Substance Abuse Treatment Programs 189 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Lokahi Treatment Centers, Inc. Program Name:Adult Substance Abuse Treatment Programs Agency Director: Jamal F. Wasan, Ph.D. Phone No.:(808 ) 883 —0922 Contact Person: Cory Causey Phone No.:(808) 969 —9292 Mailing Address: Address: P.O. Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate) 68-1845 Waikoloa Road, Ste. 224 B Address: City,ST,Zip Waikoloa, HI 96738 Email Address: ccausey@lokahitreatmentcenters.net Fax No.: (808 ) 969 —7337 Accountant/CPA: Hanako K Anderson Phone No.:( ) — Firm (if applicable): Mailing Address: Address: P.O..Box 1514 City,ST,Zip Kapaau, Hawaii 96755 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑■ Hamakua Q North Kona 0 South Hilo 0 North Kohala ❑� South Kona ❑■ North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑Youth 0 Victims of Crimes ❑i Culture and the arts 0 Aged Q■ Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities El Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY18-19 FY19-20 FY20-21 $11 ,453 $9,875 $15,000 2. Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional,cognitive,and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs; and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referrals to other community-based resources for continued recovery. *We believe in a non judgmental approach with compassion, respect and dignity for all. 3. Program Description: Lokahi Treatment Centers(LTC)Substance Abuse Programs provide comprehensive treatment services for adults at all five(5)of our office locations throughout Hawai'i Island.Treatment services are for individuals that complete a substance use assessment and through this detailed assessment are determined to be in need of treatment services that includes the provision of education to abstain from the use of substances,the development of relapse prevention skills and a treatment plan, individual counseling to address other problematic factors,and case management services. LTC's continuum of care(levels of care)includes: Intensive Outpatient, Low-Intensity Outpatient, Outpatient, Continuing/After Care, and Prevention Programs. Substance abuse has a significant impact on the entire community and creates various difficulties for individuals themselves,family members, children,employers,etc. More so,the safety of our community is impacted when substance abuse is involved;typically a rise in crimes associated with substance use begin to occur more frequently as a result of continuous use without proper treatment interventions.This creates a substantial burden and strain on the criminal justice system,service providers, and emergency medical services.As our jails and prisons become overpopulated due to the incarceration rates of drug offenses,the cost to the public is increasingly overwhelming.LTC has developed programs utilizing evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities(CARF)standards.CARF evaluates rehab facilities'abilities to meet very strict standards that factor into higher success rates for patients.LTC remains committed to providing substance treatment services that integrate mental health treatment to ensure that all clients receive the proper healthcare services to enable clients to reach long-term sobriety. 4.Total Budget&Position Count: Total Program Budget: 935,500 Total Program Position Count: 13 Total Agency Budget: 1,425,500 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate State of Hawaii,Third Circuit Court-Big Island Drug Court 25,000 State of Hawai'i,Dept.of Human Services-Substance Abuse Assessment and Monitoring 25,000 Hawai'i Paroling Authority 30,000 County of Hawaii,Nonprofit Grant Award 50,000 Managed-Care(Third Party Insurance) 805,500 TOTAL: 935,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Before the COVID-19 pandemic,we were in the process of negotiating rates with managed care providers, i.e., HMSA, UHA, etc.and requesting to develop incentive programs for Lokahi Treatment Centers to provide enhanced out-patient treatment services targeting opioid use and suicide prevention. This grant will help us to maintain the increasing number of participants,while we negotiate payment rates and incentive programs with managed-care providers, We will alsocontinue to recruit volunteers for creative fundraising activities during abnormal times. LTC is committed to meet the multiple needs of the population we serve even if it is more costly to provide these services within the CDC guidelines and State and County restrictions. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Enhance out-patient treatment plan for opioid use and methamphetamine addiction,which includes a combination of medication consultation and mental health counseling services for co-occurring disorders. We were in the middle of a mental health crisis before COVID-19 hit with suicide becoming more prevalent than ever. The effects of losing jobs, social distancing(not the norm for our culture),lock-down, losing loved ones and even the over-consumption of media reports is taking a far bigger toll on people's mental health and their wellbeing. 2. Increase strategic partnerships with communities to include, but not limited to,social services,health care facilities and support groups,that will help to expand the'access and availability of services for out-patient treatment participants so they can pursue healthy,productive,and satisfying goals while gaining the benefits of abstinence and accountability. 3. Increase additional therapy programs not paid for through managed-care providers.i.e.Music Therapy,which is very different from music in the form of entertainment. It is a clinical and evidence-based therapeutic practice that utilizes music to accomplish goals within an individual's treatment program. 4. Increase the availability and ease of access to out-patient treatment services in Kohala and Ka'u. We are currently serving these communities and would like to re-open offices there. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Increase#of clients who remain in treatment for full course of recommended services Increase by 25% Increase#of after care consultations to reduce recidivism rates Increase by 25%(Determined on case by case) Increase#of community service volunteer hours per client Increase by 25% Increase#of social supports at time of discharge-compared to admission At least 50%of Clients Increase#of clients attending additional therapy programs,i.e.music therapy At least 50% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $700,000 $50,000 Professional Fees $30,000 Operations $199,500 Supplies $6,000 Equipment Other: Other: Other: Other: Other: TOTAL $935,500 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 "How are you measuring what happens for the participants after they have participated in your program?" Lokahi Treatment Centers (LTC) TheraScribe Program is used for Assessments, Treatment Planning and Case Management. It is customized for each specific client and will track the progress of each client. LTC creates treatment plans with predetermined problems, definitions, goals, objectives, interventions, and a diagnosis. LTC also includes homework assignments in each of the individual treatment plans. Lokahi Treatment Centers (LTC) identifies the baseline measures to document changes of the treatment program for each client. LTC collects metrics at regular intervals to monitor the effectiveness of the intervention. The measures used to evaluate the program may vary depending on the program model used and the goal of the evaluation, which include demographic information, process measures, and outcome measures. LTC also utilizes three other evaluation instruments to ensure quality of our service delivery; the quality of life inventory (QOLI) which is a brief assessment of 32-items that provide life satisfaction outcomes in a scoring format on 16 areas; health, self-esteem,goals/values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, and community. This instrument will be given at the beginning of treatment upon completion of the first 90-days and at the time of full clinical discharge. It is extremely useful in mapping the clients' progression from dysfunctional patterns in the quality of their life and how they shift throughout treatment. The second instrument is a New Direction Survey which is used for pre and post treatment that is completed by both the client and clinical staff. The third is a likert scale client satisfaction survey given to all clients monthly. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: DI If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name:Adult Substance Abuse Treatment Programs ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all otheeligibility f eli ibilitrequirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, , measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs is. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hay,al p.- u„ y'.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. I / -- 2,6 -- .ZI Signature of Authorized Person Date Prrsio/cn -/660 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Increase#of clients who remain in treatment for full course of recommended services Increase by 25% Increase# of after care consultations to reduce recidivism rates Increase by 25% Increase# of community service volunteer hours per client Increase by 25% Increase#of social supports at time of discharge- compared to admission Increase by 50% Increase#of clients attending additional therapy programs, i.e. music therapy Increase by 50% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $50,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 lokahi Treatment Centers, Inc Anger Management Treatment Programs 190 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Lokahi Treatment Centers, Inc. Program Name:Anger Management Treatment Programs Agency Director: Jamal F. Wasan, Ph.D. Phone No.:(808 ) 883 —0922 Contact Person: Cory Causey Phone No.:(808 ) 969 —9292 Mailing Address: Address: P.O. Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate) 68-1845 Waikoloa Road, Ste. 224 B Address: City,ST,Zip Waikoloa, HI 96738 Email Address: ccausey@lokahitreatmentcenters.net Fax No.: (808 ) 969 —7337 Accountant/CPA: Hanako K Anderson Phone No.:( ) — Firm (if applicable): Mailing Address: Address: P.O. Box 1514 City,ST,zip Kaoaau, Hawaii 96755 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) ■ ■ Puna Hamakua ■ ❑ North Kona Q South Hilo ❑■ North Kohala ❑■ South Kona ❑■ North Hilo E■ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns Q Youth M Victims of Crimes 0 Culture and the arts 0 Aged {]Victims of Health or Social Crises 0 Needs of the poor ❑■ Physical/Emotional Disabilities Q■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $11 ,453 $9,875 $11 ,000 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional, cognitive, and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs; and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referrals to other community-based resources for continued recovery. *We believe in a non judgmental approach with compassion, respect and dignity for all. 3. Program Description: Lokahi Treatment Centers Anger Management Program has one primary goal: To help a person decrease the heightened emotional and physiological stressors associated with anger and learn how to control reactions and respond in a socially appropriate manner. To reach this goal, clients learn skills and abilities in the following areas: 1. Identifying and expressing feelings appropriately a. Client takes real and practice"Time-Outs"on a weekly basis. b. Client completes anger journal on a weekly basis. c. Client demonstrates ability to identify physical and behavioral signs of anger. d. Client demonstrates ability to identify and communicate other feelings. 2. Conflict and stress management skills a. Client demonstrates ability to manage emotional stress effectively. b. Client has been free of aggressive behaviors and domestic violence. c. Client can reduce emotional stress through positive self-talk. d. Client is able to teach peers behavioral skills and educational concepts. 3. Recognizing signs and indicators of anger management a. Client is able to recognize minimization, denial, and blaming in self and others. b. Client acknowledges complete responsibility for his/her anger. 4.Total Budget& Position Count: Total Program Budget: $85,000 Total Program Position Count: 6 Total Agency Budget: 1,425,500 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Managed Care(Third Party Insurance) 45,000 County of Hawaii,Nonprofit Grant Contract 30,000 Self-Pay 10,000 TOTAL: 85,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Before the COVID-19 pandemic,we were in the process of negotiating rates with managed care providers, i.e., HMSA, UHA, etc.and requesting to develop incentive programs for Lokahi Treatment Centers to provide enhanced out-patient treatment services targeting opioid use and suicide prevention. We are also seeking other grant funding opportunities. This grant will help us to maintain the increasing number of participants who need to attend anger management classes,while we negotiate payment rates and incentive programs with managed-care providers. We will also continue to recruit volunteers for creative fundraising activities during abnormal times. LTC is committed to meet the multiple needs of the population we serve even if it is more costly to provide these services within the CDC guidelines and State and County restrictions. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Expand on the curriculum that incorporates music therapy-music for relaxation, learning healthy outlets to redirect anger, and helping to develop a healthy emotional response to triggers 2. Expand curriculum to include tools for"Thought Disorders"for clients to be able to eliminate negative thoughts such as suicide;and a better way of getting rid of self-defeating thoughts. 3. Increase strategic partnerships with communities to include, but not limited to,social services, health care facilities and support groups,that will help to expand the access and availability of services for clients to maintain the self-control techniques and have an effective way to practice productive, healthy behaviors. 5. Increase the availability and ease of access to Anger Management Intervention Treatment Services in Kohala and Ka'u. We are currently serving these communities and would like to re-open offices there. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How ore youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Increase#of adolescents and adults enrolled into anger management treatment Increase by 25% Increase#of social supports during treatment&at the time of discharge Increase by 25% Increase#of clients who remain in treatment for full course of recommended services Increase by 25% Decrease#of episodes of extreme anger Increase by 50%(Pre&Post Evaluations) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 53,000 $30,000 Professional Fees 7,000 Operations 15,000 Supplies 5,000 Equipment 5,000 Other: Other: Other: Other: Other: TOTAL $85,000 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 "How are you measuring what happens for the participants after they have participated in your program?" Lokahi Treatment Centers (LTC) TheraScribe Program is used for Assessments, Treatment Planning and Case Management. It is customized for each specific client and will track the progress of each client. LTC creates treatment plans with predetermined problems, definitions, goals, objectives, interventions, and a diagnosis. LTC also includes homework assignments in each of the individual treatment plans. Lokahi Treatment Centers (LTC) identifies the baseline measures to document changes of the treatment program for each client. LTC collects metrics at regular intervals to monitor the effectiveness of the intervention. The measures used to evaluate the program may vary depending on the program model used and the goal of the evaluation, which include demographic information, process measures, and outcome measures. LTC also utilizes three other evaluation instruments to ensure quality of our service delivery;the quality of life inventory (QOLI) which is a brief assessment of 32-items that provide life satisfaction outcomes in a scoring format on 16 areas; health, self-esteem, goals/values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, and community. This instrument will be given at the beginning of treatment upon completion of the first 90-days and at the time of full clinical discharge. It is extremely useful in mapping the clients' progression from dysfunctional patterns in the quality of their life and how they shift throughout treatment. The second instrument is a New Direction Survey which is used for pre and post treatment that is completed by both the client and clinical staff. The third is a likert scale client satisfaction survey given to all clients monthly. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name:Anger Management Treatment Programs soe ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑( If no conflicts exist, check here. Si ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we)_understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. i (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hao.--3 ;:: _y.�oviin-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. / _ Signature of Authorized Person Date Pa f ICEo Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase#of adolescents and adults enrolled into anger management treatment Increase by 25% Increase# of social supports during treatment & at the time of discharge Increase by 25% Increase#of clients who remain in treatment for full course of recommended services Increase by 25% Decrease # of episodes of extreme anger Increase by 50%, TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $30,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Lokahi Treatment Centers, Inc Domestic VioI nce Intervention Treatment Programs 191 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Lokahi Treatment Centers, Inc. Program Name:Domestic Violence Intervention Treatment Programs Agency Director: Jamal F. Wasan, Ph.D. Phone No.:(808 ) 883 —0922 Contact Person: Cory Causey Phone No.:(808) 969 —9292 Mailing Address: Address: P.O. Box 383401 Address: city,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate) 68-1845 Waikoloa Road, Ste. 224 B Address: City,ST,Zip Waikoloa, HI 96738 Email Address: ccausey@Iokahitreatmentcenters.net Fax No.: (808 ) 969 —7337 Accountant/CPA: Hanako K Anderson Phone No.:( ) — Firm (if applicable): Mailing Address: Address: P.O. Box 1514 City,sT,zip Kapaau, Hawaii 96755 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) O Puna Q Hamakua Q North Kona 0 South Hilo Q North Kohala Q South Kona Q North Hilo 0 South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns 0 Youth g Victims of Crimes O Culture and the arts 0 Aged Q Victims of Health or Social Crises Q Needs of the poor Q Physical/Emotional Disabilities El Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $11 ,453 $9,875 $10,750 2.Agency Mission Statement: • To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults, adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional, cognitive, and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs;and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referrals to other community-based resources for continued recovery. *We believe in a non judgmental approach with compassion, respect and dignity for all. 3. Program Description: Lokahi Treament Centers(LTC)Domestic Violence Intervention (DVI)programs focuses on evidence-based, cognitive behavioral DVI services for adjudicated adult offenders,to include linkages with additional supportive services that may be provided by other community providers.The DVI program is available to adults at all five(5)office facilities operated by LTC throughout Hawai'i Island. In the last fiscal year,there has been a consistent increase in the amount of adult offenders who are referred to seek domestic violence treatment services;which prompted LTC to expand access to services to all of our locations. The DVI program services provide offenders with the knowledge and skills necessary to prevent further battering, including cognitive-behavioral skills training to strengthen their ability to make different behavioral choices and accept responsibility(accountability)for their unacceptable actions. LTC's overall program objective is to build thorough case plans focused on criminogenic needs and dynamic risk factors aimed at reducing recidivism so that all clients are able to successfully complete the program and go on to lead healthier lives free from re-offending. Domestic violence is one of the most serious social problems nationally and in Hawaii,not only for the immediate victim, but also for children. 4.Total Budget& Position Count: Total Program Budget: 185,000 I Total Program Position Count: 6 Total Agency Budget: 1,425,500 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Managed Care(Third Party Insurance) 125,000 County of Hawaii,Nonprofit Grant Contract 35,000 Adult Probation Services-State of Hawai'i 25,000 TOTAL: 185,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Before the COVID-19 pandemic,we were in the process of rate negotiations with managed care providers, i.e., HMSA, UHA, etc.for Domestic Violence Intervention treatment. Manage Care reimbursements have not increased and we are seeing our clients struggle to make their co-payments for treatment. This grant will help us to maintain the increasing number of participants,while we negotiate payment rates and incentive programs with managed-care providers, We will also continue to recruit volunteers for creative fundraising activities during these difficult times. LTC is committed to meet the multiple needs of the population we serve even if it is more costly to provide these services within the CDC guidelines and State and County restrictions. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to all individuals who are assessed and diagnosed as needing domestic violence intervention treatment services. 2. Increase the availability of domestic violence intervention treatment services to individuals that need treatment. 3. Identify and strengthen the availability of community linkages that support continuity of treatment.This will lead an increase of social support networks that will enable individuals receiving treatment services to achieve long-term healthy behaviors,thus decreasing recidivism and increasing public safety. 4. Increase the availability and ease of access to Domestic Violence intervention Treatment Services in Kohala and Ka'u. We are currently serving these communities and would like to re-open offices there. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Increase#of after care consultations to reduce recidivism rates Increase by 25% Increase#of participants who remain in treatment for full course of recommended services Increase by 25% Increase#of social supports at time of discharge-compared to admission Increase by 25% Increase#of successful referrals to other professional services Increase by 25% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $100,000 $35,000 Professional Fees $13,000 a Operations $30,000 Supplies $40,000 Equipment $2,000 Other: Other: Other: Other: Other: TOTAL $185,000 $35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 "How are you measuring what happens for the participants after they have participated in your program?" Lokahi Treatment Centers (LTC) TheraScribe Program is used for Assessments, Treatment Planning and Case Management. It is customized for each specific client and will track the progress of each client. LTC creates treatment plans with predetermined problems, definitions, goals, objectives, interventions, and a diagnosis. LTC also includes homework assignments in each of the individual treatment plans. Lokahi Treatment Centers (LTC) identifies the baseline measures to document changes of the treatment program for each client. LTC collects metrics at regular intervals to monitor the effectiveness of the intervention. The measures used to evaluate the program may vary depending on the program model used and the goal of the evaluation, which include demographic information, process measures, and outcome measures. LTC also utilizes three other evaluation instruments to ensure quality of our service delivery;the quality of life inventory (QOLI) which is a brief assessment of 32-items that provide life satisfaction outcomes in a scoring format on 16 areas; health, self-esteem, goals/values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, and community. This instrument will be given at the beginning of treatment upon completion of the first 90-days and at the time of full clinical discharge. It is extremely useful in mapping the clients' progression from dysfunctional patterns in the quality of their life and how they shift throughout treatment. The second instrument is a New Direction Survey which is used for pre and post treatment that is completed by both the client and clinical staff. The third is a likert scale client satisfaction survey given to all clients monthly. County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. g Y Program Name: Domestic Violence Intervention Treatment Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflicf or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance 0 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ■� If no conflicts exist, check here. PrI A4/651) I r- a2) Si ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to nttp://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (wel understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. i (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.havv , r.7•s. ovifn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 2 Signature of Authorized Person Date Pr474 /c8d Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase after care consultations to reduce recidivism rates Increase by 25% Increase#of participants who remain in treatment for full course of recommended services Increase by 25% Increase# of social supports at time of discharge- compared to admission Increase by 25% Increase# of clients attending additional therapy programs Increase by 25% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $35,000 Professional Fees Operations Supplies • Equipment Other: Other: Other: Other: Other: TOTAL $35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 L®kahl Treatment Centers, Inc Health & Fitness Program 192 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Lokahi Treatment Centers, Inc. Program Name:Health & Fitness Program Agency Director: Jamal F. Wasan, Ph.D. Phone No.:(808 ) 883 —0922 Contact Person: Cory Causey Phone No.:($08) g6g —9292 Mailing Address: Address: P.O. Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate) 68-1845 Waikoloa Road, Ste. 224 B Address: City,ST,Zip Waikoloa, HI 96738 Email Address: ccausey@lokahitreatmentcenters.net Fax No.: (808 ) 969 —7337 Accountant/CPA: Hanako K Anderson Phone No.:( ) — Firm (if applicable): Mailing Address: Address: P.O. Box 1514 City,ST,Zip Kapaau, Hawaii 96755 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala 0 South Kona Q North Hilo ❑South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑Youth 0 Victims of Crimes Culture and the arts 0 Aged 0 Victims of Health or Social Crises EJ Needs of the poor El Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 so $o $0 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission Is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional,cognitive,and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs; and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referrals to other community-based resources for continued recovery. *We believe in a non-judgmental approach with compassion,respect and dignity for all. 3. Program Description: LTC clients,at all levels of care,are introduced to the importance of the health and fitness aspect of recovery. In the same way that aerobics,running,and/or yoga boost serotonin production in the brain,robust physical activity also produces dopamine.Unlike the intense burst of dopamine produced when a drug hits the brain,however,the amount of dopamine released during a workout is much more moderate, allowing the brain to process the neurotransmitter at a healthy rate. Effectively,people get a natural high that is allowed to dissipate,as opposed to an artificial high that is forced on them 1;?y an illicit substance. The mental health benefits of exercise are so numerous and so strong that working out has become a very popular and widespread part of recovery programs.LTC clients get together for exercise meet-ups with a counselor and trainer. LTC's Health&Fitness Program makes working out fun,engaging,and inspiring exercise in itself,as well as a basic ingredient for boosting mental health in the face of depression,anxiety,and the temptation to drink or do drugs. The emphasis on communal support and encouragement is a massive factor in a person's mental and physical rehabilitation in the aftermath of a drug habit,providing multiple levels of protection against relapse. Recovery from a substance abuse problem does not stop at the last therapy session or the most recent support group meeting.It is an ongoing,lifelong process, but it does not have to be difficult and solitary.With the support of friends and family,and the company of like-minded individuals, health and wellness in recovery can give a person a rich,fulfilling,and healthy outlook on life. 4.Total Budget&Position Count: Total Program Budget: 50,000 Total Program Position Count: 2 Total Agency Budget: 1,425,500 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of 1-Iawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program Ur 'Ma JAnr 4b1.4. .. FY d 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawai'i,Nonprofit Grant Award 25,000 Lokahi Treatment Centers 25,000 TOTAL: 50,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Before the COVID-19 pandemic,we were in the process of negotiating rates with managed care providers,i.e., HMSA, UHA,etc.and requesting to develop incentive programs for Lokahi Treatment Centers to provide enhanced out-patient treatment services targeting opioid use and suicide prevention. Now we are adding this Health and Fitness Program to meet the critical needs of our clients in their recovery process. LTC is committed to meet the multiple needs of the population we serve even if it is more costly to provide these services within the CDC guidelines and State and County restrictions. 7. Program Objectives Using County Nonprofit Grant Program Funds: This program is an outlet to counter the social and economic changes caused by the pandemic,along with the traditional difficulties regarding treatment access and adherence,worsened during this period and aggravated our clients'clinical, psychological and psychosocial conditions. 1. Enhance out-patient treatment plan specific to the Health and Fitness Program. 2.Increase strategic partnerships with communities to include, but not limited to,social services,health care facilities, support groups,and Parks and Recreation facilities for their continued health and fitness opportunities at the public pools, gyms,tennis courts,and parks. This will help to expand the access and availability of services for out-patient treatment participants so they can pursue healthy,productive,and satisfying goals while gaining the benefits of abstinence and accountability. 3. Increase additional therapy programs not paid for through managed-care providers.i.e.Music Therapy,which is very different from music in the form of entertainment.It is a clinical and evidence-based therapeutic practice that utilizes music to accomplish goals within an individual's treatment program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 . Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) #of clients who remain in the program for the full course of recommended services 50%of Clients #of clients participating in the Health and Fitness Program 50%of Clients #of social supports at time of discharge-compared to admission 50%of Clients #of clients attending additional therapy programs,i.e.music therapy 25%of Clients #of surveys to evaluate performance measures based on patient experience 50%of Clients Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 F?21-22 Actual* Total Budget Grant Req Salary and Wages 25,000 25,000 Professional Fees Operations 10,000 Supplies 5,000 Equipment 10,000 Other: Other: Other: Other: Other: TOTAL $50,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 "How are you measuring what happens for the participants after they have participated in your program?" Lokahi Treatment Centers (LTC) TheraScribe Program is used for Assessments, Treatment Planning and Case Management. It is customized for each specific client and will track the progress of each client. LTC creates treatment plans with predetermined problems, definitions, goals, objectives, interventions, and a diagnosis. LTC also includes homework assignments in each of the individual treatment plans. Lokahi Treatment Centers (LTC) identifies the baseline measures to document changes of the treatment program for each client. LTC collects metrics at regular intervals to monitor the effectiveness of the intervention. The measures used to evaluate the program may vary depending on the program model used and the goal of the evaluation, which include demographic information, process measures, and outcome measures. LTC also utilizes three other evaluation instruments to ensure quality of our service delivery; the quality of life inventory (QOLI) which is a brief assessment of 32-items that provide life satisfaction outcomes in a scoring format on 16 areas; health, self-esteem, goals/values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, and community. This instrument will be given at the beginning of treatment upon completion of the first 90-days and at the time of full clinical discharge. It is extremely useful in mapping the clients' progression from dysfunctional patterns in the quality of their life and how they shift throughout treatment. The second instrument is a New Direction Survey which is used for pre and post treatment that is completed by both the client and clinical staff. The third is a Iikert scale client satisfaction survey given to all clients monthly. County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply); O Member or members of the Council O Staff appointed by a member of the Council The Mayor • The Managing Director O The.Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined a5;q,gb tantfai probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. • nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2a 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified, Fazed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Ilawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at j www.hawaiicount goy fn-nanorofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%o)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ^p pgµ( „1 — S'_nature of Authorized Person Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Health & Fitness Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of clients who remain in the program for the full course of recommended services 50% of Clients # of clients participating in the Health and Fitness Program 50% of Clients Increase#of social supports at time of discharge- compared to admission 50% of Clients # of clients attending additional therapy programs, i.e. music therapy 25% of Clients #of surveys to evaluate performance measures based on patient experience 50% of Clients TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $25,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award EXH I BIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 M a ila'a i Hawaii Island School Garden Network 198 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:Hawaii Island School Garden Network 3: .a ter•...u „, ., i. r Agency Director: Amanda Rieux Phone No.:(808 )640 —3637 Contact Person: Zoe Kosmas Phone No.: (952 )451 —8260 Maili.ig Address: Address: PO Box 543 Address: City,sr,zip Kamuela, HI 96743 Facili:y Address: Address: 67-1229 Mamalahoa Hwy Address: City,sr,Zip Kamuela, HI 96743 Email Address: zoe@malaai.org Fax No.: ( ) — Accountant/CPA: Christine Eason Phone No.:(808 )885 —4272 Firm :if applicable):Greenhouse Productions Mailing Address: Address: PO Box 6283 City,ST,Zip Kamuela, HI 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds:54,000 Geographical Areas:To Be Served: (One or more can be checked) • Puna Hamakua ❑■ North Kona •South Hilo [ North Kohala ❑I South Kona * North Hilo [I South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns [• Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor [_l Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONE ROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name: Hawaii Island School Garden Network 11111091311=1 11111171=111111MIESSIMIIIIIIIIIIIIIMIMIIIIIIIIMMINIO 211MW 11611111111111=11111011, 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 18,750 2.Agency Mission Statement: The:mission of Mala'ai is to cultivate connections between people, land,culture and food in school gardens. ThEe Hawaii Island School Garden Network(HISGN)cultivates the relationship among our children,our teachers and our 'aina by nourishing a vibrant network that sui:ports the growth and integration of school learning gardens.We achieve this thrcugh professional development, advocacy.mentorship,and technical assistance. • 3. Program Description: The Hawaii Island School Garden Network(HISGN)supports the 60+school learning gardens on Hawaii Island,thus connecting the keiki of Hawaii to real food, h aalthier eating habits,to their community,to their academics,and to the'aina itself.School learning gardens are experiential outdoor laboratories for students to deepen their relationship to nature, unc:erstand and apply science and mathernalics,develop healthy eating habits, incorporate social studies and language art:.,perpetuate Hawaiian cultural practices,and learn to become stewards of the land. In addition,school learning gardens are a safe context for social emotional learning where children experience teamwork,apply resilience,witness the impact of t'ieir work over time,andtdevelop a deep connection to nature;all of which contributes to their overall well-being. HISGN conducts professional development workshops during the school year to support teachers working in learning gardens around the islanc. In SY 2020-202'i, HISGN adapted the workshops to a virtual platform in response to the Covid par demic.Some of the topics included: Building Emotional Resilience for educators and parents(based on the work of Joanna Macy),Teas for Resilience, Food Frcm Wood(classroom mushroom kits), Growing Fast Foods,and Volunteers in the School Garden during Covid Times. In r=sponse to Covid, HISGN also began a new state-wide project School Garden Talk Story(SGTS), in partnership with the Oahu Farm to School Network.The SGTS has met monthly since April 2020-present, and tackles issues surrounding safely working in school gardens during the pandemic,ways to utilize home gardens as a teaching tool during distanced lea ming, as well as provides a space for networking between educators.There are currently 129 members on the facebook groip and mailing list. HISGN also supports leachers through technical assistance via phone calls or in person consultations.Between August 2020-January 2021 we have provided 20 hours of one-on-one consultations,facilitated n ...............L.........h..i...........n..d....n .....J.......x.,1....1......1.... w...F...�.,1........M...............f.....I.............,...,..m L...... El 4. Total Budget& Position Count: Total Program Budget: 73000 Total Program Position Count: 1.25 Total Agency Budget: 302 788 Total Agency Position Count: 3.25 EXHIBIT A -, NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Pro: ram Name:Hawaii Island School Garden Network 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate USDA NIFA EWD FEAST- Food Experiences for Agriculture Science Trainird15,000 USDA NIFA FASLP - Food Agriculture Service Learning project - Harvest of 67,500 Family Foundations 10000 Workshop Revenue 15000 Mala'ai Discretionary funds 5000 TOTAL: 52,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HI::IGN is working closely with the Hawaii Farm to School Hui,a project of the Hawaii Public Health Institute to financially support the workshops and trainings and to support having a school garden in every school.We are working toward a fee for service model of professional development statewide to help sustain our programs.This year, in response to the par idemic,we have opened up our workshops to parents and community members to support families with children learning at home and to reach a wider audience.We also are working with the Hawaii Island Food Alliance to identify new funding sources and potential partnerships to support this work. HISGN will continue to pursue USDA grant funding and other private grants to support the program. 7. Program Objectives Using County Nonprofit Grant Program Funds: HISGN program objectives are: 1.To develop,support,and increase the number of well-trained school garden teachers who have the expertise and capacity to carry out their work,thus perpetuating the movement for a learning garden in every school.2.To build strong inter-relationships between students,teachers and the'aina in order to deepen their connection to food, place,community,culture,and self;3.To host and nurture a network of teachers and educators around Hawaii Island,offering resources, professional development and other opportunities.4.To support the Hawaii Farm to School movement in building a more resilient and robust food system in Hawaii through the development and implementation of the Hawaii Farm to School Toolkit(FASLP). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:Hawaii Island School Garden Network 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your pr ogram?Describe,be specific.) 80 Hawaii Island teachers and educators reached through the four yi -Create pre-post survey specify 1200 teachers reached state-wide through the School Garden Talk 8-Track participants at sessionsd 250 teachers, educators, administrators, community members and rt-Maintain HISGN database ancb 30 technical assistance consultations within a year period. -Monitor contact hours, type ofd Over 12,000 Hawaii Island students educated in the 63 School Gard-Conduct yearly Island Wide sib aWork with 6 teachers to use tht As a part of the state wide initiative "Food and Agriculture Service lu-Oversee the "Harvest of the 45 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 39,000 42000 36000 Professional Fees 20000 20000 10000 Operations 8000 8000 5000 Supplies 3000 5000 3000 Equipment • Other: Other: Other: Other: Other: TOTAL 70000 75000 54000 • *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala'ai Program Name:Hawaii Island School Garden Network so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): it Member or members of the Council n Staff appointed by a member of the Council U The Mayor ❑ The Managing Director E The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: CH If no conflicts exist, check here. 4414174 Abliip 1/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:l-lawaii Island School Garden Network g1. Certification of Understanding (Page 1 of 2) I (we have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135- 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we understand that information supplied herein shall be made public according to Chapter 92F, Haw.i'i Revised Statutes. I (we understand that applications will not be reviewed by County personnel receiving our County Nonp rofit Grant submittal, and that we have full responsibility to ensure that all documents are comp lete and accurate prior to submittal. I (we understand that all documents requiring a current signature must be the ORIGINAL, SIGNED docu Trent. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as or ginal documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual regisi ration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to summit a yea r-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an expla nation of the publlic benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete acs:ounting of all expenditures supported by County of Hawaii grani funds,and a listing of other funding sources and amounts obtained during the award period. Failui.e to submit a timely, complete, ar,d accurate year-end report, using the template provided, will impa:t the evaluation of your program's or agency's future funding requests. EXHIBIT A NONF ROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:Hawaii Island School Garden Network 21. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we} understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in (7 timely manner will impact the evaluation of your agency's futur'funding request and may result i,i actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you a-e acknowledging that you have read and understood these requirements. / 414n4 ( c� 1/29/2020 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:Hawaii Island School Garden Network 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council _s Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 MV a'a i The Culinary Garden of Waimea Middle School 199 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Mala'ai Program Name:The Culinary Garden of Waimea Middle School Agency Director: Amanda Rieux Phone No.:(808 )640 —3637 Contact Person: Zoe Kosmas Phone No.:(952 )451 —8260 Mailing Address: Address: PO Box 543 Address: City,sr,zip Karnuela HI 96743 Facility Address: Address: 67-1229 Mamalahoa HWY Address: City,ST,zip Kamuela HI 96743 Email Address: zoe@malaai.org Fax No.: ( ) — Accountant/CPA: Christine Eason Phone No.:(808 )885 —4272 Firm ;if applicable): Mailing Address: Address: PO Box 6283 City,ST,Zip Karnuela HI 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds:55000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Hamakua ❑ North Kona South Hilo N North Kohala n South Kona n North Hilo 111 South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns [III Youth n Victims of Crimes n Culture and the arts n Aged n Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities • Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala'ai Program Name:The Culinary Garden of Waimea Middle School 111631131911111 =1131131TEMINIIIMMINTIMMISIMMIN 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 • 2. Agency Mission Statement: The mission of Mala'ai is to cultivate connections between people, land,culture and food in school gardens. Ma a'ai:The Culinary Garden of Waimea Middle School cultivates the relationship between students and the land through gro wing and sharing nourishing food in our outdoor living classroom.Our work reaches beyond the boundaries of our garden connecting land stewardship,culture,health and pleasure with lifelong learning. • 3. Program Description: Mala'ai:The Culinary Garden at Waimea Middle School is a food-based educational program that has been providing innovative and exceptional hands-on education for students and adult members of Waimea Community for 15 years. By providing a safe,outdoor learning environrne it for all students, Mala'ai works to address the need for inclusive,equitable, culturally-responsive agricultural practices that help students and adults cultivate meaningful engagement with the health of their communities,their environment, and themselves.This program focuses on enhancing classroom curriculum and STEM learning, and helps to improve overall student performance by encouraging curiosity and providing real world examples.We utilize the garden as an outdoor living laboratory to reinforce classroom concepts using principles of nature anc. regenerative agriculture. Due to Covid W3 have been adapting our programming to accommodate for new safety precautions,school closures and a rapidly changing education system. In response to covid in sp-ing 2020,WMS began delivering Kokua Kits with student worksheets/class materials,donated snacks,and gifts from the garden,to all students on a bi-weekly basis.Mala'ai provided produce from the garden,fresh anc:dried herbal teas,gardening information,activities,seeds,and planting materials for students to use at home. Mala'ai also assisted WMS staff with assembly and celivery.This effort has continued and in the 2020-21 school year,Mala'ai has sent home over 1400 kokua kits with lessons,crops,seeds and recipes,and produced 7 educational videos to accompany lessons.We collaborate with the Extended Care classes to offer extra credit to students who completed the activity.These videos are sent to students via google classroom,as well as archived on the Mala'ai website,instagram,facebook and youtube pages. Mala'ai traditionally collaborates with all PE/Flealth, Ike, BPA,AVID and Science classes to host students in the garden .d..:�.. r ,,..i...1...{........I...,.............L.......h...l{.,..,4.,,,+.. .F...m.,{�....�.�.�.{..........mm...A..{......F..{............ {�.........,.1...... 4. Total Budget& Position Count: Total Program Budget: 172000 Total Program Position Count: 2 Total Agency Budget: 302788 Total Agency Position Count: 3.25 • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:rhe Culinary Garden of Waimea Middle School 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Waimea middle school contributions 20000 Unrestricted foundation grants 70000 HCF restricted community grants 30000 Individual Donations 10000 Retail market sales 15000 • TOTAL: 145000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: , As a well established non-profit and program of 16 years,our plans to increase revenue include identifying new funders, and expanding our fundraising efforts.With new technologies brought on by Covid,we hope to utilize online resources and networking to find new partners with aligned Ideals to fund our project.We have-also been accepted into the Kamuela Farmers Market which will allow us to interact with the community and connect with new residents and potential funders. • 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of Mala'ai:The Culinary Gardan of WMS are:to provide a safe,alternative learning environment for the most underserved youth of Waimea where students develop critical thinking skills to make healthy choices through garden activities and place-based learning;to highlicht special guests such as cultural practitioners and local professionals to expose our students to cultural and career opportunities;to provide food and garden materials to our school community;to remain relevant with our communications and utilize online methods of teaching and learning. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:The Culinary Garden of Waimea Middle School 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How ore youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Provide 1000 hours of student engagement in the garden to achievt-Utilize our well-developed evah Donate at least 1500 lbs of crops and planting material to students,d-record harvest weights and dill Create 8 informational videos on garden lessons and home gardenii-create post survey to collect sit Participate in Kokua Kits to provide 235 WMS students with garderd-Create online surveys to gathj Collaborate with teachers and attend faculty meetings to provide reh-attend weekly extended core to Achieve 400 volunteer hours -maintain volunteer relationshigi Maintain malaai.orq website, email list, and social media to provided-track engagements on social r� Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 139000 140000 40000 Professional Fees 8000 10000 5000 Operations 10000 14000 8000 Supplies 4000 8000 2000 Equipment Other: Other: • Other: Other: Other: _ TOTAL 161000 172000 55000 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2021-22 Agency Name:Mala'ai Program Name:The Culinary Garden of.Waimea Middle School io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): E[( Member or members of the Council 0 Staff appointed by a member of the Council ❑ The Mayor la The Managing Director. II The Director of Finance 0 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflkt of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefis accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential confl cts of interest: If no conflicts exist, check here. • riTali'( (2'(-P'w' l 1/29/2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONF ROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:The Culinary Garden of Waimea Middle School a1. Certification of Understanding (Page 1 of 2) I (we; have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135- 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we;agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, eqr,ipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we; understand that information sup plied herein shall be made public according to Chapter 92F, Hami'i Revised Statutes. I (we; understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we; understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of}lawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the pubic benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, ar d accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Mala`ai Program Name:The Culinary Garden of Waimea Middle School n. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we} understand that failure to submit the final report within 60 days of June 30th shall result in loss of all :rant funds received durin: the •:rant •eriod must be refunded to Count and exclusion from future :rant •artici s ation for a minimum of one ear or until a written res ort is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:j1rwww.hawaiicounty.govjfn-nonprofit-grant-forms]on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs.. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 44'!al?% PibtA79 1/29/2021 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Mala'ai Program Name:The Culinary Garden of Waimea Middle School 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment r: ()the Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 9 Mental Health Kokua Case Management 204 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management Agency Director: Greg Payton CEO Phone No.: (8( 173x— 2523 Contact Person: Julie Agno CSD Phone No.: (8019 7619— 5725 Mailing Address: Address: Mental Health Kokua q Address: 1221 Kapiolani Blvd Ste 345 city,ST,Zip Honolulu, HI 96814 Facility Address: Address: Mental Health Kokua Address: 208 Wainaku Avenue City,sT,zip Hilo, HI 96720 Email Address: gpayton@mhkhawaii.org,jagno@mhkhad Fax No.: (801936- 1212 Accountant/CPA: Summer Uwono Phone No.: (g 7 Firm (if applicable): N/A 1 2523 �f Mailing Address: Address: 1221 Kapiolani Blvd Ste 345 City,ST,zip Honolulu, Hi 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 15,000 Geographical Areas To Be Served: (One or more can be checked) SiPuna n Hamakua North Kona j South Hilo JAI North Kohala n South Kona n North Hilo ❑■ South Kohala ■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns I]Youth IN Victims of Crimes ❑ Culture and the arts n Aged n Victims of Health or Social Crises Needs of the'poor IC Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0 $0 Sp 2. Agency Mission Statement: Mental Health Kokua's (MHK) believes that all citizens should have an opportunity to live and participate in and contribute to their communities. Through specially designed services and settings, Mental Health Kokua helps people in Hawai'i who are in mental distress, emotional crisis or recovering from serious mental illness, achieve their optimum level of recovery and ability to function in the community. MHK's primary service philosophy for case management is the recovery model. 3. Program Description: Mental Health Kokua's Community Based Case Management Program provides goal-oriented and individualized supports focusing on improved self-sufficiency for the persons served through assessment, planning, linkage, advocacy, coordination, and monitoring activities. Successful service coordination results in community opportunities and increased independence for the consumer. MHK's Case management is provided with person-centered planning and delivered by a team of internal employees of MHK, with the sole purpose of providing case management/services coordination. Services are designed and implemented to support the recovery, health and well-being, enhance the quality of life, reduce symptoms, build resilience, restore and improve functioning and support the integration of the consumer into the community (CARF, 2020). Mental Health Kokua's Case Managers work with other community providers to develop an individualized support network to assist persons served to achieve optimal recovery, and be a contributing member of the community. 4. Total Budget& Position Count: Total Program Budget: 945,000 Total Program Position Count: 12 Total Agency Budget: 12,682,333 Total Agency Position Count: 33 EXHIBIT A if NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County Of Hawaii 15, Ohana Insurance(CCS)State of Hawaii DHS program 00 930,000 000 TOTAL: 945,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Mental Health Kokua intends to maintain our consumer census at above 90% capacity in order to maintain and increase revenue. Mental Health Kokua is making efforts, and will continue to make efforts to secure additional grant funding from trusts and foundations. In addition, fund raising events are held to support our program and the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide Case Managment services to 250 unduplicated consumers. 2. Limit Psychiatric hospitalizations to less than 5%. 3. At least 85% of consumers served are satisfied with services received. 4. At Discharge, 85% of consumers will have achieved their treatment plan goals. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of unduplicated consumers served 250 %of consumers requiring psychiatric hospitalization Less than 5% %of consumers satisfied with services received At least 85% %of consumers discharged who achieved treatment goals At least 85% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 468,039 482,080 15,000 Professional Fees 20,000 20,900 Operations 280,000 288,950 Supplies 45,286 46,645 Equipment60 Other: Mileage Reimbursement , 20 61,929 43,200 44,496 Other: Other: Other: Other: TOTAL .916,650 945,000 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director n The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: \\, 1 If no conflicts exist, check here. VI Llt/ M Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to,submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authoriz pi Person Date Greg Payton, CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Case Management 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of unduplicated consumers 250 % of consumers requiring Psychiatric Hospitalization Less than 5% % of consumers satisfied with service received At least 85% %of discharged consumers who achieved treatment goals At least 85% TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages $15,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Mental Health Kokua Residential Rehabilitation 205 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Agency Director: Greg Payton CEO Phone No.: (8Q6)73E1— 2523 Contact Person: Julie Agno CSD Phone No.: (80a9 7619— 5725 Mailing Address: Address: Mental Health Kokua q Address: 1221 Kapiolani Blvd Ste 345 City,ST,Zip Honolulu, HI 96814 Facility Address: Address: Mental Health Kokua Address: 208 Wainaku Avenue City,ST,Zip Hilo, HI 96720 Email Address: gpayton@mhkhawaii.org, jagno@mhkhaa Fax No.: (8 )9313— 1212 Accountant/CPA: Summer Uwono Phone No.: Firm (if applicable): N/A (8C�173�— 2523 Mailing Address: Address: 1221 Kapiolani Blvd Ste 345 City,ST,zip Honolulu, Hi 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 15,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ®I Hamakua North Kona 0 South Hilo n North Kohala n South Kona n North Hilo El South Kohala 0 Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ! I Youth 0 Victims of Crimes ❑ Culture and the arts n Aged n Victims of Health or Social Crises IMO Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY19-20 FY20-21. $6675 $5750 $0 2.Agency Mission Statement: Mental Health Kokua assists people with mental health and related challenges, to achieve optimum recovery and functioning in the community. Mental Health Kokua provides housing, case management, and outpatient services on behalf of Hawaii citizens, and those with severe and persistent mental illness and co-occurring disorders since 1973. 3. Program Description: Mental Health Kokua's Residential Rehabilitation Program is designed to provide a "highly structured residential environment where the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability" (CARF, 2020). MHK's housing structure includes daily classes, counseling, and individual activities. Residents are assigned responsibilities within the therapeutic living community. MHK's group homes "emphasize the integration of an individual within their community, and progress is measured within the context of that therapeutic community's expectation" (CARF, 2020). Services support the person-served in their recovery, which consists of reducing symptoms, building resilience, restoring and improving functioning, and supporting the integration of person-served into the local community. An individual service plan is developed with person served to include individualized measurable goals such as finding independent housing, obtaining a GED, finding a job, addressing behavioral health and medical needs, etc. to help achieve optimal recovery for the person served. 4. Total Budget& Position Count: Total Program Budget: 1,554,769 Total Program Position Count: 36 Total Agency Budget: 12,682,333 Total Agency Position Count: 280 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County Of Hawaii 15,000 State of Hawaii-DOH 1,373,769 United Way funds 6,000 Service/program fees 160,000 TOTAL: 1,554,769 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Mental Health Kokua intends to maintain our occupancy at above 90% in order to maintain and increase revenue. Mental Health Kokua is making efforts, and will continue to make efforts to secure additional grant funding from trusts and foundations. In addition, fund raising events are held to support our program and the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide Residential Rehabilitation services to 140 unduplicated consumers. 2. Limit Psychiatric hospitalizations to less than 3%. 3. At least 95% of consumers served are satisfied with services received. 4. Improvement in daily living skills score(ILSS) from admission to discharge. 5. At Discharge, 75% of consumers will transition to more independent housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation B. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they hove participated in your program?Describe,be specific.) Number of unduplicated consumers served 140 %of consumers requiring psychiatric hospitalization Less than 3% %of consumers satisfied with services received At least 95% Improvement of daily living skills score(ILSS)from admit to discharge At least 75% %of consumers discharged to more independent housing At least 75% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 1,050,286 1,082,769 15,000 Professional Fees 38,800 40,000 Operations 334,650 345,000 Supplies 53,500 55,000 Equipment 31,040 32,000 Other: Other: Other: Other: Other: TOTAL 1,508,276 1,554,769 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council I I Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 1)(1 If no conflicts exist, check here. c447--; t/t 4/1624 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. \ 4-"1 Signature of Authori��d Person Date Greg Payton, CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of unduplicated consumers 140 % of consumers requiring Psychiatric Hospitalization Less than 3% % of consumers satisfied with service received At least 95% Improvement of daily living skills score (ILSS) from admit to discharge At least 75% % of consumers discharged to more independent living At least 75% TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages 15,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Na'allehu Main Street, Inc. Haumana A'o 'Oihana '0 Ka'u 206 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc Program Nam Haumana A`o `Oihana '0 Ka'0 Agency Director: Sharman O'Shea Phone No.:(808 ) 256 —3193 Contact Person: Sharman O'Shea Phone No.:(808 )256 —3193 Mailing Address: Address: PO Box 446 Address: City,ST,Zip Naalehu Facility Address: Address: 94-6488 Kamaoa Road Address: City,s-r,zip Naalehu, HI 96772 Email Address: NaalehuMainStreetlnc@gmail.com Fax No.: ( ) — Accountant/CPA: Meleana Smith Phone No.:(808) 929 —8000 Firm (if applicable): Kau Business Center Mailing Address: Address: PO Box 6239 City,ST,Zip Ocean View, HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna n Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth Victims of Crimes Culture and the arts ❑Aged Victims of Health or Social Crises n Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: Haumana A'o 'Oihana '0 Ka'O 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $8 ,625. 00 2. Agency Mission Statement: The purpose and mission of Na'alehu Main Street, Inc. is to foster and appreciation for Na'alehu and its history while improving the economic vitality through community-based economic development, planning and education while creating projects that meet the health, safety and well-being of the community. 3. Program Description: Haumana A'o'Oihana'O Ka'u is an apprentice program designed especially for young people who want to explore their creativity to become self-sufficient and self-reliant. By becoming an apprentice matched with and working hand-in-hand with local professionals and skilled entrepreneurs who will offer technical support, resources, guidance, motivation and inspiration to assist them in creating a successful business. 4.Total Budget& Position Count: Total Program Budget: 31 ,000.00 Total Program Position Count: 21 Total Agency Budget: 41 000.00 Total Agency Position Count: 22 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: Haumana A`o `Oihana `O Ka'u 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Grants 31,000.00 Fundraising and Donations 10,000.00 TOTAL: 41 ,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to increase revenues through partnering with other non-profits in the community, providing scholarships and hosting fundraising events 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objective is to create a six month apprentice program that will match local professionals to ten inspired young people to help them discover their passion and create a livelihood. Business professionals to provide guidance and materials to help the apprentice create a successful business endeavor.That will enhance the economy and create well-being in the community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: Haumana A'o 'Oihana 'O Ka'0 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Participants become self sufficient Improves Local Economy Increases creativity Participants Discover their calling Learn a trade Participants start a business Create Jobs Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees 3,000.0 3,000.0 Operations 5,000.0 5,000.0 Supplies 5,000.0 5,000.0 Equipment Other: Mentors 18,000. 18,000. Other: Other: Other: Other: TOTAL 31 ,000. 31 ,000._ *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: I Haumana A`o `Oihana 'O Ko`u 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, reaardless of whether a conflict exists. NAME: Sharman O'Shea POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council ❑n The Mayor l❑ The Managing Director ❑n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. rm cep a�( l 2_,8 2-02-1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: Haumana Al() 'Oihana 'O Ka'u 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 9 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: I Haumdna A'o 'Oihana 'O Ka'Ci 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1128/2021 Sign. - of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: Haurnana A'o 'Oihana '0 Ka`u 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Contract with 20 mentors Complete Contract with 10 Apprentices Complete Create guidelines and goals Complete Match Mentors with Apprentices Complete Create ten new businesses CompletE Follow-up Complete Graduation Complete TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 3,000.00 Operations 5,000.00 Supplies 5,000.00 Equipment Other: Mentors 18,000.00 Other: Other: Other: Other: TOTAL 31 ,000.00 Additional Council directives regarding award: We look forward to giving ten young people a chance to work with seasoned professionals to create new business in our community. EXHIBIT B • NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 N � , MainStreet,eet Inc. Raised Garden Initiative 207 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Na'alehu Main Street, INc Program Name:wised Garden Initiative Agency Director: Sharman O'Shea Phone No.:(808 ) 256 —3193 Contact Person: Sharman O'Shea Phone No.;(808 ) 256 —3193 Mailing Address: , Address: PO Box 446 Address: City,ST,zip Naalehu Facility Address: Address: 94-6488 Kamaoa Road Address: City,ST,zip Naalehu, HI 96772 Email Address: NaalehuMainStreetlnc@gmail.com Fax No.: ( ) - Accountant/CPA: Me)eana Smith Phone No.:(808) 929 —8000 Firm (if applicable): Kau Business Center Mailing Address: Address: PO Box 6239 City,ST,Zip Ocena View, HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Puna ❑ Hamakua U North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational ccncerns Youth n Victims of Crimes n Culture and the arts .".o Z Victims of Health or Social Crises v I Needs of the poor P Physical/Emotional Disabilities o Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLI:ATION FY 2021 -2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Naalehu Main Street Inc Program Name: Raised Garden Bed Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 I FY 19-20 FY 20-21 8 , 625 . 00 2. Agency Mission Statement: The purpose and mission•of Na'alehu Main Street is to preserve and maintain the historic Na'alehu Business District, foster an appreciation for Na'alehu history while improving the economic vitality through community-based economic development, planning and education. Create and inspire projects that meet the health, safety and well-being of the community. • • 3. Program Description: Implement a Raised Garden Bed Initiative to source, prep, install,fill and plant fifty 20sq ft. raised garden beds to qualified participants living in the Ka'u Region of Hawaii Island. To establish a larger group of small scale food producers it the community to help to improve food security of low-income households, increase access of local produce and enable greater economic stability.The raised beds will be completely installed with a treated wooden frame, soil, mulch, compost and a selection of plants and herbs. Participants will receive guidance on maintaining their garden.Workshops and classes will be offered to teach participants how to prepare and preserve their garden fresh produce and herbs. • • 4.Total Budget& Position Count: Total Program Budget: 35,000 Total Program Position Count: 2 Total Agency Budget: 457000 Total Agency Position Count: 2 EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc, Program Name: Raised Garden Bed Initiative 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Donations 5,000 Grant 30,000 TOTAL: 357000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Offer Raised Garden Beds to those with more financial resources Gardening and Composting Workshops and Classes Cooking Food Prep Workshops and Classes 7. Program Objectives Using County Nonprofit Grant Program Funds: Assemble, deliver and fill 50 Raised Garden Beds in the Kau District of Hawaii Island with an edible garden. Establishing a larger group of small scale food producers in the community to help improve food security of low-households, increasing access to local produce and enabling greater economic stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Naalehu Main Street Inc Program Name: Raised Garden Bed Initiative 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Particpants will have an established garden Participants will save money on groceries Participants will have more food security . Participants will enjoy fresh food that they grow Particpants may be healthier eating food they_grow Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees 1 ,000 Operations 5,000 Supplies 1 ,000 Equipment Other: Contractor Assemble / Deliver/ Setup Boxes 5,000 Other: Lumber, screws and sealant _ 7,500 other: Seedlings ! 5,000 Other: Soil/Mulch/Compost _ 10,5500 Other: TOTAL 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street Program Name: Raised Garden Bed Initiative E •—.�'.'w .€.ay.Y2,,Z..»iT�^Y'w..w' '...., ..»......:.ai'..: U:..,,..: �.tx..x tku^+» :......�......x..:w.;u,...:......:x L-+:>L.<z�..:.a'a.',..:3.A..b rwu..,.e.",,.c.s.4.,.s.........G.....z................+..,..?' °.s ,'w7 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Sharman O'Shea POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Memberor members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor E❑ The Managing Director ❑ The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counse , or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. (.2'771 2C)2___.1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc. Program Name: Raised Garden Bed Initiative ±1. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspectiany facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have thei authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate1prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc, Program Name: Raised Garden Bed Initiative 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt : /www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County if Hawai'i with the final report. Failure to return these funds in a timely manner will impact the eva'uation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 27,7 202 Signatureiof Authorized Person Date Executive Dirctor Title/Position of Author',ized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Na'alehu Main Street, Inc, Program Name: Raised Garden Bed Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Present offer to community/Interview and C Complete Order Lumber/Screws/Sealant Ordered Puchase Soil/Mulch/Compost Delivered Hlre Contractor Done Schedule Delivery and Set Up Done Assemble and Plant Garden Boxes Complete TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 1 000 Operations 5,000 Supplies 1 000 Equipment Other: Independent Contractor 5,000 Other: Lumber, screws and sealant 7 500 _ Other: 600 Seedling herbs and ply 5 000 Other: Soil, Mulch & Compost 1 0,000 Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Neighborhood Place of Puna Family Resource Center 208 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center Agency Director: Paul Normann Phone No.:(808 )965 —5550 Contact Person: Paul Normann Phone No.:(808 )965 —5550 Mailing Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Email Address: paul@neighborhoodplace.org Fax No.: (808 )965 —5109 Accountant/CPA: Tiffany Parsons Phone No.:(808 ) 968 —1002 Firm (if applicable): Carbonaro CAPs & Management Group Mailing Address: Address: 136 Kinoole City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) n Puna ❑ Hamakua E North Kona 0 South Hilo U North Kohala ❑South Kona ❑ North Hilo n South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) Fill Educational concerns ❑Youth I Victims of Crimes ❑ Culture and the arts ❑Aged Pi]Victims of Health or Social Crises I®! Needs of the poor ❑ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 X16,425 $11 ,505.00 $12,375.00 2.Agency Mission Statement: The goal of Neighborhood Place of Puna is to prevent child abuse and neglect by ensuring that families have access to the resources and skills they need to raise their children in safe,stable,and nurtruing homes. Mission Statement:Empowering families and communities in Puna and East Hawaii by building strong foundations through healthy relationships that value each person's uniqueness. E Malama Pono Kakou. 3. Program Description: Child abuse and neglect can have lifelong impacts on the health,well-being, and success of children. Hawaii County continues to have the highest rates,per capita,of child abuse and neglect in the State.The majority of incidents of child maltreatment occur in Puna and South Hilo. Neighborhood Place of Puna serves families with underage children and expecting mothers, in Puna and South Hilo.As a Family Resource Center,we use an evidenced based approach using the Protective Factors.The Protective Factors are conditions or attributes in families that mitigate risk and increase the health and well-being of children and families. As a Family Resource Center,we help parents find resources, supports,or coping strategies that will allow them to parent effectively,even under stress.This may involve helping families address immediate needs such as food, clothing,and housing.NPP has many resources in house:An Emergency Family Shelter,Drop in Therapeutic Counseling,Housing Navigators and Homelessness Prevention Specialists, Parent Educators and Resources, Diaper Bank,Clothing and Hygiene Closet,etc.We also connect families to outside resources and professionals services.These may include rent and utility assistance,medical services,financial assistance and education,educational supports,child-care, etc. All services are free and voluntary.Services can be provided electronically—phone,video conference—in the home,in the community, or in the office.We are one of the very few organizations that exist to provide a wide range of supportive services to families in East Hawaii. 4.Total Budget& Position Count: Total Program Budget: $233,000 Total Program Position Count: 3 Total Agency Budget: 2,081,097.00 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Blueprint for Change(State DHS funding) 153,000.00 County of Hawaii 25,000 Hawaii Island United Way 5,000 Foundation Grants 30,000 Contributions and other revenue 20,000 TOTAL: 233,000 Attach additional pages,if needed. b. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is a successful child abuse and neglect prevention program servicing a community that lacks many resources, has a high level of poverty,and has some of the highest rates of child abuse and neglect, per capita,in the State.ALICE data for Hawaii County reveals that families—especially single parent households—experience extremely high rates of poverty. Needless to say, COVID-19 has hit families particularly hard,adding the responsibility and stress of homeschooling on top of the pandemic created economic instability, health fears,and general anxiety. Families need more help and support now than ever. Neighborhood Place of Puna is continually seeking funding to support our Family Resource Center. When possible,we identify elements of the program that can pursue specific supplemental funding,such as our therapeutic counseling program,or our homelessness prevention services.But the core of the Family Resource Center—Parenting Education, Resource Navigation,Case Management—is always going to require financial support from the government to ensure that there is always place families can turn to get the support,resources, and skills necessary to raise their children in a safe, stable,and nurturing home. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of the Family Resource Center is ensuring that families have access to the resources and skills they need to raise their children in safe,stable,and nurtruing homes. We seek to achieve our primary objective by focusing on the six following areas: 1. Ensuring that families have access to sufficient food,stable housing,and basic resources 2. Ensuring that families have access to needed medical services and providers 3. Ensuring that children in the home are connected with and participating in school 4. Reducing risks of child abuse and neglect by addressing areas of high concern such as developmentally inappropriate parenting,unsafe living environment,lack of essential resources,and/or high levels of parental stress/anxiety,etc. 5. Strengthening families through Parenting Education and Ongoing Family Support(Case Management),and Connectivity to Financial Resources/Education,Job Training,and Employment resources,etc. 6. Building resilience by helping families expand their own social support networks EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Ongoing support and connectiving to resources 50 families • Family Needs and Safety Assessment 50 families Development of Individualized Service Plan(ISP)to address needshisks 50 families Families will successfully complete their Individualized Service Plan(ISP) 80%of families Families who successfully complet ISP will be free of Child Abuse 6 months from program completion 80%of families Attach additional pages as necessary. 9.TABLE H: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 202,171 202,171 25,000 Professional Fees 11,125 1,625 Operations 24,006 21,474 Supplies 3,980 3,980 Equipment 500 0 Other: Mileage 7,500 3,750 Other: Other: Other: Other: TOTAL $249,282 233,000 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): • Member or members of the Council O Staff appointed by a member of the Council • The Mayor O The Managing Director O The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. • Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. cC �� ar 1 /26/21 ignature o uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. we understand that applications will not be reviewed byCountypersonnel receivingour County ) pp Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). i (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and irislrucliuiis due available dt hitp://www.hawalicounty.gov/in-nonprofit-grant-forms/on or dbuut May 30 of the year the final report is due. Aspaof this application,you acknowledge that anyfunds awarded will be restricted cted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 /26/20 Signature of Authorized Person Date Paul Normann Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Neighborhood Place of Puna Program Name: Family Resource Center 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Ongoing support and connectiving to resources 50 families Family Needs and Safety Assessment 50 families Development of Individualized Service Plan (ISP)to address needs/risks 50 families Families will successfully complete their Individualized Service Plan (ISP) 80% of families Families who successfully complet ISP will be free of Child Abuse 6 months from program completion 80% of families TABLE 9I: EY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $25,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 North Kohala Community Resource Center Kohn la Cares-Weekly Food Drive 209 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name:Kohala Cares - Weekly Food Drive Agency Director: Leslie Nugent Phone No.:(808 )889 —5523 Contact Person: Leslie Nugent Phone No.:(808 )889 —5523 Mailing Address: Address: PO Box 519 Hawi, HI 96719 Address: City,ST,zip Hawi, HI 96719 Facility Address: Address: 55-3393 Akoni Pule Hwy Address: City,ST,zip Hawi, HI 96719 Email Address: Leslie@northkohala.org Fax No.: ( ) — Accountant/CPA: Steven T Doi, CPA Phone No.:(808 ) 591 —8420 ext. 26 Firm (if applicable): Doi CPA LLC Mailing Address: Address: PO Box 11773 City,sr,zip Honolulu, HI 96828 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,260.00 . Geographical Areas To Be Served: (One or more can be checked) Li Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑� North Kohala ❑South Kona n North Hilo ❑ South Kohala ❑ Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged 0 Victims of Health or Social Crises El Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Cares -Weekly Food Drive 1111111411111 4 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $0 $0 $0 2. Agency Mission Statement: North Kohala Community Resource Center's(NKCRC) mission is to support successful community projects that benefit N orth Kohala. We accomplish this mission by providing education,training,and bridges to funding. NKCRC was founded in 2002 and currently serves as a fiscal sponsor for 85 community projects. NKCRC has been a recipient of COH non- profit grant funding on behalf of numerous projects including most recently, Wastestream, Ho'ola Honey Bee. Relocation, Kohala Radio and Kohala Coqui Coalition. In addition, NKCRC received and successfully completed a COH Coronavirus Relief Fund Grant to support community feeding programs. One of NKCRC's sponsored projects is Kohala Cares whose mission is to provide supplemental food including fresh prod uce through weekly food drives for residents in need. Kohala Cares was launched in March 2020 in response to the pande mic as a means to provide food to those affected by the evolving face of hunger and has consistently hosted a community food distribution each week since then. Founded by Peter Pomeranze, owner of Sushi Rock restaurant in Hawi, Kohala C ares originally operated out of the restaurant location as it wasclosed during the pandemic. Staff members served as volun teers and previous restaurant patrons donated to support the cause. As Sushi Rock has closed Kohala Cares has partnered with the Kohala Village HUB to host the weekly distributions. Community members and restaurant patrons reco gnize the pivot Pomeranze and Sushi Rock made to serve theneeds of the North Kohala Community and continue to dona to to supplement these efforts. 3. Program Description: Before the pandemic, Feeding America reported that food insecurity, a household's inability to provide enough food for every person to live an active, healthy life was the lowest it had been in decades. Still, 1 in 8 Hawaii residents were facing food insecurity just two years ago. Since COVID19,these numbers have increased on Hawaii Island as a result of a record rate of unemployment due to the tourism sector being shut down.With this many families and individuals are experiencing an increased need for supplemental basic resources such as food. Kohala Cares responded to this need by creating a weekly food drive to serve the North Kohala community. Each week with the help of ten or more volunteers, Kohala Cares puts on a food drive and distributes approximately 150 bags of dried, canned, and local fresh produce. Through the socially-distanced drive-through distribution,the bags are distributed to families in cars serving approximately 450 community residents each week. Since the onset of the pandemic,food insecurity in Hawaii has grown by more than 50 percent, representing the fifth-highest percentage increase in the United States.As closures and social distancing guidelines extend across our communities,the impact is being felt by more and more members of our community.While these changes are disrupting the lives of nearly everyone in one way or another,those who struggle with hunger find themselves in a particularly vulnerable situation,and the number of people facing hunger is increasing at an alarming rate. Now, nearly a quarter of a million Hawaii.residents are currently struggling with hunger.Among them are out-of-work parents,isolated kupuna, and 1 in 4 keiki.The statewide food insecurity rate for 2020 was projected to be 16.8%, but the figure was far greater for children at 29.4%. Kohala Cares was initiated as a response to these community needs in Kohala due to COVID19. 4.Total Budget& Position Count: Total Program Budget: $97,438.00 Total Program Position Count: 1 Total Agency Budget: $251,229.00 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Cares - Weekly Food Drive 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate See attachment. • TOTAL: $97,440.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since its inception, Kohala Cares has solely depended on donations from generous donors of Hawaii and beyond. Kohala Cares has raised$42,061 since March of 2020 through GoFundme, Paypal,and cash/check donations.Additionally, through its partnerships,Kohala Cares has raised close to$6,000 through in-kind donations in the form of local produce and rental space.Although the project has been successful in raising such funds,it is understood that diversified funding is necessary as the needs and accommodations grow.Through its fiscal sponsor, NKCRC, Kohala Cares hopes to secure grants to help support its services. Kohala Care's goal for 2021-22 is to create a grant calendar with its fiscal sponsor and apply to a minimum of six grants to diversify funding streams. Kohala Cares will also develop an ask to distribute to local businesses and other corporate sponsorship opportunities for cash and in-kind donations. 7. Program Objectives Using County Nonprofit Grant Program Funds: Through County nonprofit grant program funds Kohala Cares will provide the following services in FY 2021-2022: A. Provide a weekly food drive serving 150 North Kohala families each week over 52 weeks during the project period between July 1,2021-June 30,2022. If the need grows, Kohala Cares would like to expand its food drive offerings to twice per week. B. Purchase a variety of 13 different non-perishable food items and local produce.Some items will be distributed in duplication to reach a minimum of 20 items per bag. Items to be included are pasta, rice,canned goods,drinks,snacks, oatmeal,soup,granola bars,plus fresh produce,toiletries,and pet food collected from donations.Additional local produce will be purchased when needed. C. Solicit and schedule 10 weekly volunteers through outreach to assist with food shopping,transportation,bag packing, and distribution. D. Solicit in-kind donations in the form of fresh produce,toiletries,pet food,or other goods to supplement bags each week and increase nutritional content through local fruits and vegetables. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • :Agency Name: North Kohala Community Resource Center Program Name: Kohala Cares Weekly Food Drive #5. Program Funding Sources ,. ' g { g`$ 2021: a `" trk f ,� "i'.�i to 4 4.61 y6-iidy tiai -•'x4 7.'s. +e ,aF4ui; ,. '`.``,.'t�,.�,�S Utf044-X.0 County NP Grant 2021-22 $10,260.00 Hawaii United Way $2,500.00 Dorrance Family Foundation $6,000.00 Matson Community Giving $1,500.00 HEI Charitable Foundation $1,500.00 y A s�44�+ �� vx `�� �t��'#��, ... ,s. ., a_ ��,�;t'r�,,, ,..sv� �vu' z . Individual Donors $54,500.00 1Heart Hub $9,780.00 Kohala Gleaning $7,800.00 Kokua Harvest $3,600.00 T� ►1. $97,440 Q4 1 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Cares - Weekly Food Drive 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of N. Kohala residents served through food drives 450 individuals Number of food drives provided during the project timeline 52 food drives Number of bags distributed each week 150 food bags Number of volunteers to assist with food drive each week 10 volunteers Number of volunteer hours donated each week 15 hours Amount of local produce donated annually 600 lbs Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $0 $18,000.00 $2,000.00 Professional Fees $0 $0 $0 Operations $3,260.00 $9,780.00 $0 Supplies $46,200.00 $60,770.00 $7,000.00 Equipment $0 $0 $0 Other: Transportation $1,253.00 $1,670.00 $500.00 Other: Indirect Costs (8%) $4,057.00 $7,218.00 $760.00 Other: Other: Other: TOTAL $54,770.00 $97,438.00 $10,260.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Cares - Weekly Food Drive 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): Di Member or members of the Council 01 Staff appointed by a member of the Council ® The Mayor Di The Managing Director El The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. j(j‘Autivi 1/ZIEei ( Sig ure of Authorized P son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Cares - Weekly Food Drive 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we] understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name:Kohala Cares - Weekly Food Drive ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. / i Ai / Ad lir/Zef14 • Signa 'e of Authorized Person / Date Ca i 0 i'ra4er,L Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name:Kohala Cares - Weekly Food Drive 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 North Kohala Community Resource Center Kohala Unupa'a Mauka to Makai Summer Camp 210 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:North Kohala Community Resource Center Program Name:Kohala Unupa'a Mauka to Makai Summer Camp Agency Director: Leslie Nugent Phone No.:(808 )889 —5523 Contact Person: Leslie Nugent Phone No.:(808) 889 —5523 Mailing Address: Address: PO BOX 519 Address: City,ST,zip Hawi, HI, 96719 Facility Address: Address: 55-3393 Akoni Pule Hwy Address: City,ST,zip Hawi, HI, 96719 Email Address: Leslie@northkohala.org Fax No.: (808 ) 889 —5527 Accountant/CPA: Steven T Doi, CPA Phone No.:(808) 591 —8480 ext 26 Firm (if applicable): Doi CPA LLC Mailing Address: Address: PO BOX 11773 city,sr,zip Honolulu, HI, 96828 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 5,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑Hamakua ❑ North Kona ❑South Hilo Q North Kohala ❑South Kona ❑ North Hilo ❑■ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) - ■❑ Educational concerns Q Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑■ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 2. Agency Mission Statement: North Kohala Community Resource Center(NKCRC),is a 18-year-old, 501(c) non-profit with a mission to support successful community projects that benefit North Kohala.We accomplish this by providing education, training and bridges to funding. We currently sonsor 85 community projects and have been the fiscal sponsor for Kohala Unupa'a since 2013. Kohala Unupa'a is a thriving year round program in its nineth year of serving upper elementary and middle school students in North and South Kohala.The program offers after-school and school break programming that focuses on coastal and marine conservation and restoration through a lens that integrates Native Hawaiian cultural practices with modern scientific technologies. The mission of Kohala Unupa'a is to inspire youth to find and follow their path of heart, raising consciousness by facilitating reconnection with nature, Hawaiian culture, community, spirit, 'ohana and oneself. Kohala Unupa'a provides students with a foundation in Hawaiian culture through the oral histories of our kupuna, using the Hawaiian language, and hands-on experience with traditional Hawaiian skills in relationship with the'aina. 3. Program Description: Mauka to Makai is a Summer Camp offered by Kohala Unupa'a in it's ninth year that focuses on coastal and marine conservation and restoration through a lens that integrates Native Hawaiian cultural practices with modern scientific technologies.The summer camp portion has grown consistently over the years and this year will feature a three week day camp and five night overnight camp from July 6-July 30,2021.The number of students served has also doubled since its inception to now serve 25 students.Within the group there is a leadership team made up of students who have participated in the program in the past who now serve as mentors for the younger students.The overnight portion of camp is tailored specifically for the leadership team which is about 5-7 students. During the Mauka to Makai Summer Camp students learn about the richness of Hawaiian culture, deepen their connection and learn about their kuleana to care for the'aina. Students work with mentors and kupuna to develop ancestral skills of fishing, hunting,farming and gathering, learning how to live off what the'aina can offer us to make tools, clothing and gifts. They learn'oli, hula,and at least one new Hawaiian word each day and use the words in context.The camp has traditionally culminated in a ho'ike for family in which campers present'oli, mele, hula and demonstrate other skills they have learned. We recognize that this year we will need to modify our camp practices to be in alignment with COVID-19 health and safety precautions. If we are unable to host all students together at one time,we will split our group into three and each group will participate in camp for one week. Our camp has been historically supported and partially funded by the 21st Century Learning Centers Grant through the Kohala School Complex.This year, our school does not have 21st Century Grant funding and thus we are expanding our outreach for support to include the County of Hawaii. 4.Total Budget& Position Count: Total Program Budget: '5 U'LI(pt! Total Program Position Count: 2 PT Total Agency Budget: 251229 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate COH non-profit Grant 5000 NOAA 2000 HAPA Fund 1000 Running Strong Foundation 10000 Nanea Foundation 5000 Healy Foundation 5000 Community Donations and In-kind 2500 TOTAL: 30500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Kohala Unupa'a works with a diverse group of funders to support our year-round educational programming.We will continue to work with local donors,family foundations and national organizations such as NOAA to increase revenue for our programming.We have received funding from NOAA for the past three years to support our after-school program and will continue to apply for federal funding to support our programs and supplement our local funding. In addition,when conditions are appropriate,Kohala Unupa'a hosts fundraisers such as T-shirt and LauLau sales.We will continue these efforts when it is safe to do so. • 7. Program Objectives Using County Nonprofit Grant Program Funds: Objectives for Kohala Unupa'a Mauka to Makai 2021 summer camp(July 6-July 30,2021)are: -Host a three week day camp focusing on coastal and marine conservation and education serving 25 students in North Kohala and Kailapa in Kawaihae. -Host a 5 night overnight leadership camp for 5-7 students -Introduce 25 students to reproductive cycles and lifecycles of shoreline limpets,invertebrates and near shore fish; significant cultural and historical sites in North Kohala and safe boating and fishing practices. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of students served 25 Number of students introduced to reproductive cycles and Recycles of shoreline limpets,invertebrates and near shore fish 25 Number of students introduced to significant cultural and historical sites in North Kohala 25 Number of students introduced to safe boating and fishing practices 25 Number of students participating in leadership training 7 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 5,000 10,000 1,100 Professional Fees 1200 Operations Supplies 1814 Equipment • Other: Meals 1,800 5069 1,000 Other: Transportation 5,300 7431 2500 Other: Insurance 2600 Other: Admin (8%fiscal sponsorship fee) 960 2350 400 Other: TOTAL 13060 30464 5000 *If applicable ?kose. not: Fy 26-2-1 (4, S repse-5en.(-5 Csrdutse 1 elack 'Sf Cp ' P u(q.rle a .s look rt i-s K.,it Ga.wt p r 0A- '-\cA Glu-t- IcVCavt( -1°t. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): A Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor O The Managing Director fl The Director of Finance • [� The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 171 If no conflicts exist,check here. / 1 C9/.(01 (frieVL 174c12,67.( ature of Authorized rson (sVecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program fcr which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai`i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely;complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30t!'shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ie/ / r jt [ Zc "Z0Z 1 l ature of Authorized Per n Date C.x' — Di r -e2 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North.Kohala Community Resource Center Program Name: Kohala Unupa'a Mauka to Makai Summer Camp 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 North Kohala Community Resource Center North Kohala Golf Park 211 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:North Kohala Community Resource Center Program Name:North Kohala Golf Park Agency Director: Leslie Nugent Phone No.:(808 )889 —5523 Contact Person: Leslie Nugent Phone No.:(808)889 —5523 Mailing Address: Address: PO Box 519 Address: City,ST,zip Hawi, HI 96719 Facility Address: Address: 55-3393 Akoni Pule Hwy Address: City,ST,zip Hawi, HI 96719 Email Address: Leslie@ northkohala.org Fax No.: (808 ) 889 —5527 Accountant/CPA: Steven T Doi, CPA Phone No.:(808) 591 —8480 ext 26 Firm (if applicable): Doi CPA LLC Mailing Address: Address: PO Box 11773 • city,ST,Zip Honolulu, HI, 96828 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 5,400 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑Hamakua ❑ North Kona ❑South Hilo 111 North Kohala ❑South Kona ❑North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ■❑Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 2.Agency Mission Statement: North Kohala Golf Park is a fiscally sponsored project of the North Kohala Community Resource Center(NKCRC),an 19-year-old,501(c)3 nonprofit serving the district of North Kohala.The mission of NKCRC is to support community projects that benefit North Kohala.NKCRC does this by providing education, a fiscal umbrella, and bridges to funding, along with coaching and support for a wide range of community efforts.Currently NKCRC sponsors 85 community projects that include youth,sports, senior,arts,education, equine, cultural, agricultural and land preservation programs. NKCRC is responsible for ensuring that grant funds are spent appropriately and all reporting is completed fully and on-time. NKCRC has been the fiscal sponsor for North Kohala Golf Park since 2017. North Kohala Golf Park(NKGP),located in Kapa'au behind Kamehameha Park,is a recreation area for children to learn and play golf and for adults to practice their skills.Our mission is to provide the best low cost golf park to the community that we can.The 14 acre, 9-hole course has a putting and chipping practice area.The golf park has been part of this community since the 1990's and has been enjoyed by many.The course closed in 2016 and became overgrown when the manager left the island;this prompted a group of volunteers to come forward to make it operational again. Since then the group has purchased necessary equipment, improved the course, opened the course for community use and hosted youth after school programs. The project is currently managed by volunteers Chelsea and Abe LaFrance. Chelsea is a teacher and active community organizer and Abe, has worked and played golf since he graduated from high school and currently serves as the Superintendent for the Hapuna Golf Course. Their leadership has established and retained other volunteers from our island's golf industry to help support and maintain the course. 3. Program Description: The North Kohala Golf Park is a 9 hole community golf course with a putting green and a driving range.The course is open 7 days a week to all that want to get out and play.The course serves families,seniors and youth through afterschool and school break programming. The cost to play golf is affordable and the rates have not increased for two decades, with the intention of keeping this a true community initiative available to all.Adults pay$12 per day, seniors$10 per day and youth always play free of charge. Right now the playing conditions on the course are not up to par.With proper greens the youth are given a better chance to learn the right way of playing golf and will hopefully lead them to loving the sport and being good enough to get scholarships for college in the future.Senior citizens that use the course regularly would benefit greatly from the better playing conditions. Many of the golfers who enjoy the course are elderly women who want to get out doors and do something. Improvements to the course will enable more community members to enjoy golf. In addition, a community partner is working with the golf course to install a disc golf course that will use the same greens but provide a supplementary activity and source of income. Covid-19 brought many challenges to the course. Not only did it shut down youth afterschool programs but it caused the course to close for a short period of time.Support from the County will help to make improvements so that when youth programs are able to be held at the park again the course is ready to give them more than before.Additionally, with many youth sports and afterschool programs on hold and the increase in digital learning,families are looking for more opportunities to get outside and engage in physical activity together.The Golf Park provides a safe outdoor environment where groups can maintain social distancing guidelines and COVID-19 precautions. 4.Total Budget&Position Count: Total Program Budget: 70,000 Total Program Position Count: 1 Total Agency Budget: 251,229 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Annual Membership Fee 5,000 Day Fee 20,000 Grants 10,000 Donations 15,000 IN-kind 20,000 TOTAL: 70,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: NKGP works with various revenue streams to support the parks year-round programming. With repaired greens and increased accessibility for our players we intend to see an increase in revenue from daily golf fees. In addition, as awareness of and visibility of the golf course grows,we intend to see an increase in the number of community donations that come in to support the course. With the leadership of the LaFrance's and support from NKCRC,the golf park is applying for various sources of grant funding. The golf park hopes to expand this funding to include national golf associations and sponsors as well.The addition of a disc golf course will also expand income opportunities for the golf course. In addition, in-kind support continues to increase with more professionals in the field working together to improve the course. 7. Program Objectives Using County Nonprofit Grant Program Funds: With COH non-profit grant funds in FY 2021-2022 the objectives of the North Kohala Golf Course are to: 1)Regrass each of the nine golf course greens by installing Paspalm grass 2)Host 300 individual games of golf per month 3)Host 100 school-aged students for afterschool and school break educational programming at the golf course 4)Install an 18 hole Disc-Golf Course on existing golf course EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Regrass golf course greens 9 Games of golf played each month 300 Number of students exposed to golf education and training 100 Number of participants introduced to Disc Golf 500 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 12,000 15,000 0 Professional Fees Operations Supplies 7,500 10,500 2,000 Equipment Other: Greens Installation 0 22,000 3,000 Other: Equipment Maintenance and repair 7,500 7,500 0 Other: Disc Golf 0 7,000 0 Other: Fuel 4,000 4,000 0 Other: Admin (8% fiscal sponsorship fee) 2,000 4,000 400 TOTAL 31,200 70,000 5,400 *If applicable . EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): Q Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Fl If no conflicts exist, check here. .. Ai.0111AI d-A / /zzj Signa i of Authorize• Person (s -sly title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we)understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement - to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. z5-770-7, Si ure of Authorized Pers Date C9) f\-) I ( e.U-1-07L Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Golf Park 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 'o Ka'Cu Kakou Family Fun Fest 212 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest Agency Director: Wayne KaWachi Phone No.:(808 ) 937 —4773 Contact Person: Nadine Ebert Phone No.:(808 ) 938 —5124 Mailing Address: Address: P.O. Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop City,ST,Zip Pahala, HI 96777 Email Address: okaukakou.org@gmail.com Fax No.: ( ) — Accountant/CPA: Phone No.:( ) - Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $8,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes ❑ Culture and the arts g Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest • 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,000 $5,858 $6,125 2. Agency Mission Statement: '0 Kau Kakou was organized exclusively for charitable,educational, cultural, and economic support of the people of Ka'u. Operating income and assets are acquired entirely by donations,grants, and fund raisers. '0 Ka'u Kakou is a 100 percent volunteer run community service organization that responds to a wide variety of needs, often partnering with other community groups to achieve its goals. The mission statement reads:To support and promote a healthy community through education,cultural, and economic development opportunites that improve the quality of life in in rural Ka'u. 3. Program Description: This is an annual family-oriented event held in conjunction with the`O Ka'u Kakou sponsored Independence Day parade in Na'alehu. We provide fun and healthy activities for all ages. These activities include inflatable water slides,train, and rock wall for the keiki. Then the families are treated to hot dogs,watermelon, and shave ice for lunch. For the kupuna,we have bingo where they are served a special lunch and eveyone goes home with a prize. 4.Total Budget& Position Count: Total Program Budget: $9,000 Total Program Position Count: 0 Total Agency Budget: $94.130 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Family Fun Fest 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County grant $8,000 Donations $1,000 TOTAL: $9,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Any help we get from the Countyhelps us not only with this project, but it also helps us give more to the community projects that are not covered by grant money. We are always seeking monetary and in-kind donations. We have also scheduled fund raising projects such as selling hot dogs and shave ice (and sometimes coconuts and oranges)at Punalu'u Black Sand Beach and other locations around Ka'u. 7. Program Objectives Using County Nonprofit Grant Program Funds: This is a program to provide a fun day for keiki,their families, and the kupuna of Ka'u.While celebrating our nation's birthday with a parade,we bring families together to have a fun day in the park.Additionally,the Ka'u kupuna always look forward to playing bingo, einning household products, and having lunch.This project meets our mission statement of supporting and promoting a healthy community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Family Fun Fest 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they hove participated in your program?Describe,be specific.) Due to COVID restrictions,our 2021 celebration will be severely restricted 300 hot dogs and watermelon slices 650 hot dogs and watermelon slices 350 shave ice 750 shave ice 0 bingo players(no bingo in 2021 due to COVID) 400 volunteer hours 620 volunteer hours 0 parade units(no parade in 2021 due to COVID) • Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment 2,000 3,000 2,500 Other: Advertising 250 2,000 1,600 Other: Security 150 150 150 Other: Food 2,000 2,000 2,000 Other: Prizes 1,950 1,750 Other: Musicians 1,000 TOTAL 5,400 9,000 8,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council 0 Staff appointed by a member of the Council • The Mayor O The Managing Director fl The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 1:11 If no conflicts exist, check here. ie4/0..e /26(',1j-ate ) ) 6i.7) Sign ure of Authorized Person (specify titlidi Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: `O Ka'u Kakou Program Name: Family Fun Fest 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `0 Ka'u Kakou Program Name: Family Fun Fest 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. „ 4 640 N /27 ijeZ2/ Signature of Authorized Person Date Title/Position of Au fiorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment 2,500 Other: Advertising 1,600 Other: Security 150 Other: Food 2,000 Other: Prizes 1,750 Other: TOTAL 8,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 `w Ka'l Ki kou Ka'u Veterans' Day Celebration 213 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: '0 Ka'u Kakou Program Name:Ka'u Veterans' Day Celebration Agency Director: Wayne Kawachi Phone No.:(808 ) 937 —4773 Contact Person: Nadine Ebert Phone No.:(8o8 ) 938 —5124 Mailing Address: Address: P.O. Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop City,ST,Zip Pahala, HI 96777 Email Address: okaukakou.org@gmail.com Fax No.: ( ) — Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $3,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) El Educational concerns ■❑Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 $2,510 $3,000 2. Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable,educational, cultural, and economic support of the people of Ka'u. Operating income and assets are acquired entirely by donations,grants and fund raisers.'O Ka'u Kakou is a 100 percent volunteer run community service organization that responds to a wide variety of needs, often partnering with other community groups to achieve its goals. The mission statement reads:To support and promote a healthy community through education,cultural, and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: While there are other Veterans'Day celebrations scattered around the island,there is nothing in Ka'u.When we organized this in 2018,we wanted to let our Veterans now we appreciate their service to our country.Many attendees were very thankful that we had started this day of celebration for them. In 2020,we had 82 Veterans attend this event. We gave them$15 vouchers to use at any of the vendors at the Farmer's Market.This helped promote the vendors,and also gave the Veterans a way to take advantage of local grown organic food and locally made crafts. A local organization put together exhibits honoring the service of our many Kau citizens. We also gave out free watermelon and provided music to the day-long event. 4.Total Budget& Position Count: Total Program Budget: $4,000 Total Program Position Count: 0 Total Agency Budget: $94,130 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County grant $3,000 Donations $1,000 TOTAL: $4,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are always looking for new sources for donations and are fortunate to have businesses to support us. Unfortunately, we were not able to get as much community support in 2020 due to COVID. 7. Program Objectives Using County Nonprofit Grant Program Funds: This event brings people together for a day of fun,food, and entertainment while honoring the Veterans of Ka'u. Various support agencies have exhibits offering Veteran services, and there were several exhibits honoring the service of Veterans of Kau through pictures and newspaper articles.We hope this event continues to build on a sense of community that fosters pride in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) In 2019,we served 250 lunches. Due to COVID we made changes in 2020. 2021,we expect to serve 250 lunches 250 lunches Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees $1,000 $1,000 $1,000 Operations Supplies $ 200 $ 600 $ 200 Equipment Other: Other: Food $1,230 $1,600 $1,200 Other: Advertising $ 600 $ 800 $ 600 Other: Other: TOTAL $3,030 $4,000 $3,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 " County of HawalG i Nonprofit Grant Application FY2021-22 Agency Name: `0 Ka'u Kakou Program Name:Ka'u Veterans' Day Celebration 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): Member or members of the Council 10 Staff appointed by a member of the Council 101 The Mayor The Managing Director 10 The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ell If no conflicts exist, check here. --9jettztkka N14.4) c)/ Signiture of Authorized Person (specify titl Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name:Ka'u Veterans' Day Celebration 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name:Ka'u Veterans' Day Celebration ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. r -ilk' Af rzi digt, J ) % )gid 1 J Signature of Authorized Person Date 7412410. -11 Title/Position of 4 horized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `0 Ka'u Kakou Program Name:Ka'u Veterans' Day Celebration 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees $1,200 Operations Supplies $ 200 Equipment Other: Food $1,200 Other: Advertising $ 600 Other: Other: Other: TOTAL $3,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 °o Ka% K( kou Ka'u Sanitation 214 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Agency Director: Wayne Kawachi Phone No.:(808 ) 937 —4773 Contact Person: Nadine Ebert Phone No.:(808 ) 938 —5124 Mailing Address: Address: P.O. Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop City,ST,Zip Pahala, HI 96777 Email Address: okaukaou.org@gmail.com Fax No.: ( ) — Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑North Hilo ❑South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u Sanitation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $9,300 $3,345 $8,125 2.Agency Mission Statement: 'O Kau Kakou was organized exclusively for charitable,educational, curtural, and economic support of the people of Ka'u.Operating income and assets are acquired enitrely by donations grants, and fund raisers.'0 Ka'u Kakou is a 100 percent volunteer run community service organization that responds to a wide variety of needs, often partnering with other community groups to achieve its goals. The mission statement reads: To support and promote a healthy commuity through education,cultural, and economic development opportunities that improve the quality of life in Ka'u. 3. Program Description: For many years'0 Ka'u Kakou has provided and maintained two portable toilets at the boat ramp at the Punalu'u Black Sand Beach. Providing these portable toilets a the boat ramp area helps keep this area clean and allows people to enjoy the beauty we are so proud of in Ka'u. Last year we added two new portable toilets that we maintain for the Na'alehu Farmer's Market. For fifteen years the Farmer's Market had been located in front of the ACE Hardware in Na'alehu,and last year they moved to land that'O Ka'u Kakou is purchasing for future senior housing. This move allowed more vendors to join the Farmer's Market,thus benefitting the economic health of the Ka'u community. Providing two portable toilets at this site provides needed sanitation units for both the vendors and the shoppers(including tourists). The Farmer's Market is so successful that currently there are 350 shoppers on an average Wednesday. 4.Total Budget & Position Count: Total Program Budget: $9,000 Total Program Position Count: 0 Total Agency Budget: $93,130 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: `0 Ka'u Kakou • Program Name: Ka'u Sanitation 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County grant $9,000 TOTAL: $9,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: While we feel that this is one of our more important programs because of the environmental and health benefits,we find that it is hard to get additional outside support for this less glamorous project. 7. Program Objectives Using County Nonprofit Grant Program Funds: These fund will help 'O Ka'u Kakou not only continue providing portable toilets at Punalu'u Black Sand Beach, but they also give us the opportunity to help out at a weekly event that benefits many people in Ka'u and those traveling through. h. While we have not done a study on the number of visitors and fishermen at the Black Sand Beach,the popularity of the portable toilets is measurable. They are serviced once a week.This weekly schedule was determined.based on the need to empty the toilets and keep the area clean. The toilets at the Farmer' s Market are also emptied weekly. In addition to the 40 vendors,an average of 350 shoppers (including tourists)come on Wednesdays. The market is also open on Saturdays,but attendence is much lower. By providing portable toilets at this site,we are fulfilling a necessary community need. We know of no plans for anyone to install restrooms at either of these two locations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u SanitationT B.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Two protable toilets at Punalu u Black Sand Beach Two portable toilets Two portable toilets at Na alehu Farmer's Market Two portable toilets Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations $9,500 $9,000 $9,000 Supplies Equipment Other; Other: Other: Other: Other: TOTAL $9,500 $9,000 $9,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u Sanitation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): El Member or members of the Council Of Staff appointed by a member of the Council O The Mayor `If The Managing Director The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 'I If no conflicts exist, check here. 1) 7 1./ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u Sanitation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i • grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `0 Ka'u Kakou Program Name: Ka'u Sanitation ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 61/1.1 i.211.2621 Signa ure of Authorized Person Date Title/Position ofthorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: `o Ka'u Kakou Program Name: Ka'u Sanitation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations $9,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $9,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Pacific Tsunami Museum Tsunami Education through Distance Learning 216 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Pacific Tsunami Museum Program Name:Tsunami Education through Distance Learning Agency Director: Marlene Murray Phone No.:(808 ) 935 —0926 Contact Person: Marlene Murray Phone No.:(808) 987 —0704 Mailing Address: Address: P.O. Box 806 Address: City,ST,Zip Hilo, HI 96721 Facility Address: Address: 130 Kamehameha Avenue Address: City,ST,zip Hilo, HI 96720 Email Address: director@tsunami.org Fax No.: ( ) — Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $21,866 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna 0 Hamakua ❑■ North Kona ❑■ South Hilo ❑■ North Kohala ❑■ South Kona ❑■ North Hilo ❑■ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns ■❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of.Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $7,125 $11 ,913 $9,875 2.Agency Mission Statement: We believe that through education and awareness, no one should ever again die due to a tsunami. 3. Program Description: The Pacific Tsunami Museum will create online educational content for students and teachers. Content will feature videos of tsunami presentations incorporating the science of tsunamis,the history of tsunamis in Hawaii and the impact on the community,survivor stories,impactful photos and videos,and important safety information. The presentations will be created for the 4th grade,6-8th grade,and high school levels. Staff will develop the content,create the presentations and produce the filmed presentations. A Project Manager will coordinate the project,serve as a liaison with the Department of Education and individual schools and teachers and provide support for the process. Video production equipment and software will be purchased to create the videos. A graphic designer will be contracted to create printable materials to be used as aids in classroom/distant learning as a supplement to the videos. 4.Total Budget& Position Count: Total Program Budget: $21,866 Total Program Position Count: 2 Total Agency Budget: $226,339 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate We currently do not have other sources of funding to support this program FY 21-22. 0 TOTAL: 0 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since admissions, membership dues and donations only cover our year to year expenses,we continue to pursue grants and other fundraising opportunities. Additionally,the museum has been closed,due to the pandemic,since March 2020, which has halted all sources of revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: The threat of tsunamis is an ever-present reality to all who live in the Hawaiian Islands. Scientists and experts agree that it is not a matter of if, but when the next one will strike. The Pacific Tsunami Museum's mission is to save lives though education and awareness. Because of the worldwide pandemic,the Pacific Tsunami Museum was forced to temporarily close in March 2020. Dozens of scheduled school groups were cancelled. Although the museum anticipates opening sometime in 2021,school groups are not expected to return for a while. The online experience will not be the same as visiting the museum,but it is crucial that the important information still reach our students. In a typical year,thousands of students visit the museum. This online content will help fill the gap and assist teachers to meet their science goals and objectives. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Teachers will submit a registration form and will then be forwarded a link to the educational videos. 1,000 students Registration information,which will include the number of students expected to view the presentations, will allow for tracking the numbers. Additionally,the number of video"Views"will be monitored. An evaluation form will be sent to the teachers,and feedback will be used to make improvements in the program. Positive feedback and successes will also be collected as part of the evaluation data. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 6180 6180 Professional Fees 2186 2186 Operations Supplies 500 500 Equipment 5000 5000 Other: Project Manager 5000 5000 Other: Graphic Artist 1500 1500 Other: Web Support 1000 1000 Other: Scientific Adviser 500 500 Other: TOTAL 21866 21866 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Marlene Murray POSITION: President/CEO May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): �❑ Member or members of the Council ❑ Staff appointed by a member of the Council ® The Mayor �❑ The Managing Director • The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ID If no conflicts exist, check here. Marlene M U rra Digitally signed by Marlene Murray 1/28/21D y ate:2021.01.2813:13:10-1000' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Marlene MurrayDy Diate:2021 01 28y13:13 43 n10'00' 1/28/21 Signature of Authorized Person Date President/CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education through Distance Learning 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Teachers will submit a registration form and will then be forwarded a link to the educational videos. 1,000 students Registration information,which will include the number of students expected to view the presentations, will allow for tracking the numbers. Additionally,the number of video"Views"will be monitored. An evaluation form will be sent to the teachers,and feedback will be used to make improvements in the program. Positive feedback and successes will also be collected as part of the evaluation data. TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 6180 Professional Fees 2186 Operations Supplies 500 Equipment 5000 Other: Project Manager 5000 Other: Graphic Artist 1500 Other: Web Support 1000 Other: Scientific Adviser 500 Other: TOTAL 21866 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 PETIFIX Spay and Neuter Spay and Neuter Clinics 217 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics Agency Director: Beate Neher Phone No.:(808 )989 —4075 Contact Person: Beate Neher Phone No.:(808 )989 —4075 Mailing Address: Address:p 0. Box 1275 Address: City,ST,Zip Keala kekua, HI 96750 Facility Address: Address: P. O. Box 1275 Address: city,ST,Zip Kealakekua, HI 96750 Email Address: petfixbigisland@gmail.com Fax No.: ( )NA — Accountant/CPA: NA Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona 0 North Hilo ❑South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises O Needs of the poor ❑Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PETFIX Spay and Neuter Program Name: Spay and Neuter Clinics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 NA NA NA 2.Agency Mission Statement: PETFIX Spay and Neuter works to protect Hawaii's environment by providing safe and professional spay and neuter services on the Big Island at free clinics.We educate the public about the impact of pet overpopulation and the welfare of animals across the island.Our long-term goal is to offer these services island wide. 3. Program Description: PETFIX will conduct 5 spay/neuter clinics for small animals with requested project funds. Clinics will be conducted at no cost to pet owners.At least 3 of the clinics will be conducted in Ka'u,the county's largest district and one of its poorest. In-person outreach and education will be conducted at the Ocean View flea market to prioritize participation by lower-income pet owners and raise awareness of pet overpopulation issues. Additional outreach and education will be conducted online. Each clinic will sterilize approximately 50 animals. PETFIX will spay or neuter at least 250 animals during the funding period.An unsterilized female cat can produce 12 kittens in a single year;an unsterilized dog can produce an average of 7 puppies. The county's investment of$10,000 will thus prevent harm to the environment and the public's health from approximately 2,500 unwanted animals in the first year alone. Many people in Ocean View,Ka'u's largest subdivision, have complained about the danger posed by unwanted animals,such as feral dogs harassing children and livestock. PETFIX has gathered an experienced leadership team which has demonstrated significant success during its first full year of operation. Each of the 5 board members has from 15 to 40 years of experience in animal welfare and/or nonprofit administration. A group of 30 volunteers show strong community support by donating at least 80 hours during each clinic. Despite COVID shutdowns,the agency fixed over 1,500 animals at 30 clinics during 2020. Overall,the agency plans to conduct a minimum of 24 clinics during the next fiscal year,sterilizing at least 1,200 animals. In addition to the clinic hours,community members demonstrate strong commitment to the program's goals. A participant at one of the Hilo clinics has committed to trapping and fixing the whole kitten community in his neighborhood. 4.Total Budget&Position Count: Total Program Budget: 21,750 Total Program Position Count: 2 contracted,30 volunteer Total Agency Budget: 96,500 Total Agency Position Count: 2 contracted,30 vdunteer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PETFIX Spay and Neuter Program Name: Spay and Neuter Clinics 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County grant request,5 clinics @$2,000 10,000 Donations for supplies,5 clinics @$750 3,750 Volunteer hours @$20/hour,80 hours/clinic 8,000 TOTAL: 21,750 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Funds are requested from the county to conduct 5 spay/neuter clinics,and PETFIX aims to conduct an additional 19 clinics during the project period. Additional funds come from a variety of sources. Donations are accepted at all clinics. Pet owners donate what they can afford for the service,and all revenues go toward providing more spay/neuter clinics. Donations are also gathered from online services such as Amazon Smile, Network for Good,and Facebook fundraisers. More than$35,000 cash was donated in the organization's first full year of operation. An additional 2,400 hours of labor were donated at a value of$48,000. Community members also donate goods,which are then sold online or at the Ocean View flea market.A regular booth at the flea market provides an opportunity to educate the public about pet overpopulation as well as raise funds. Almost $15,000 was raised last year,despite months of COVID closure. More is expected this year if the market maintains regular operations. Collaboration with other organizations is a third source of revenues. Hawaii Rainbow Rangers and Aloha Ilio contracted with PETFIX to conduct their clinics in 2020. Those contracts generated almost$37,000 and a successful track record with established organizations. Additional contracts and other grant sources will be sought in 2021 and beyond to sustain this program. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Conduct a minimum of 5 free spay/neuter clinics during the project period. a.At least 3 clinics will be conducted in the low-income Ka'u district. 2.Spay or neuter at least 250 animals during the project period. 3. Sustain the program with active outreach efforts. a. Maintain an active volunteer base sufficient for 80 volunteer hours per clinic. b. Conduct outreach events to raise awareness of the project. i. Distribute information to raise project awareness at 12 in-person events in Ka'u during the project year. ii.Create online publicity for each clinic. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) A minimum of 250 animals will no longer be able to reproduce and cause harm to public health or the environment Al least 200 low-income pet owners will have their petaterirsd free orduuge and ha free of the financial burden doming for unwanted animals. An estimated 2,500 unplanned,potentially feral animals will be prevented in the first year of the project. PETFIX will sustain its mission by growing its volunteer base by 10%during the year. 1,500 people will become more aware of pet overpopulation issues thanks to 12 in-person and 5 virtual outreach events. PLEASE SEE ATTACHMENT FOR MORE LEGIBLE TABLE Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees • 70,019 72,000 10,000 Operations 5,483 6,000 0 Supplies 9,297 18,000 0 Equipment 0 0 0 Other: advertising 496 500 0 Other: Other: Other: Other: TOTAL 85,295 96,500 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit. Grant Application FY2021-22 Agency Name:PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Eli Member or members of the Council in Staff appointed by a member of the Council ® The Mayor El The Managing Director i� The Director of Finance fl The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to.an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. 69,suLk Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ZWok-k-- tlzgIZoZI Signature of Authorized Person Date President Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Free sterilization clinics conducted 5 Animals who can no longer.reproduce and cause harm to health or the environment 250 Pet owners with animals who can no longer reproduce (owners presumed to be low-income) 200 Unwanted, unplanned, potentially feral animals prevented (estimate) 2,500 Volunteers to further the agency's mission and the project objectives(10%growth rate) 33 Awareness of pet overpopulation raised through 12 inperson and 5 online outreach events 1,500 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 10,000 Operations 0 Supplies 0 Equipment 0 Other: 0 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 PETFIX Spay and Neuter Spay and Neuter Clinics Program County of Hawai'l Nonprofit Grant Application, FY 2021-22 Because of formatting issues in Item 8, here is a more legible copy of Table I, Program Performance Outcomes: • A minimum of 250 animals will no longer be able to reproduce and cause harm to public health or the environment. • At least 200 low-income pet owners will have their pet sterilized free of charge through 5 clinics and be free of the financial burden of caring for unwanted animals. • An estimated 2,500 unplanned, potentially feral animals will be prevented in the first year of the project. • PETFIX will sustain its mission by growing its volunteer base by 10% during the year. • 1,500 people will become more aware of pet overpopulation issues thanks to 12 in-person and 5 virtual outreach events. Pohaha I Ka Lani Mahina 'Ai 218 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Pohaha I Ka Lani Program Name:Mahina 'Ai Agency Director: KOlia Tolentino-Potter Phone No.:(808 )937 —4243 Contact Person: Kulia Tolentino-Potter Phone No.:(808 )937 —4243 Mailing Address: Address: PO Box 412 Address: City,ST,Zip Kurtistown, HI 96760 FacilityAddress: Address: 17-4519 Huina Road Address: City,ST,Zip Kurtistown, HI 96760 Email Address: pohahaikalani@gmail.com Fax No.: ( ) — Accountant/CPA: Chris Hannigan Phone No.:(808)930 —4024 Firm (if applicable): Midnight Oil LLC Mailing Address: Address: 525 Kilauea Ave., STE 250 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua ❑ North Kona Q South Hilo ❑ North Kohala ❑ South Kona ID North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) O Educational concerns ['Youth ❑Victims of Crimes ▪ Culture and the arts 0 Aged ❑Victims of Health or Social Crises Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 'Ai 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20 - 21 so so so 2.Agency Mission Statement: Established in 2001, Pohaha I Ka Lani is a Hawaiian-led 501 c3 nonprofit organization whose mission is to revitalize and advance indigenous Hawaiian culture. Pohaha I Ka Lani conducts place-based land stewardship,cultural education, and community engagement at sacred places surrounding Waipi'o Valley(Hamakua District)and Ola'a(Puna District)on Hawai'i Island.We offer the community meaningful, enriching opportunities to malama'aina and understand the significance of Waipi'o Valley as a wahi pana. Since 2007, Pohaha I Ka Lani has served as leaseholder of Bishop Museum lands at Napo'opo'o and Apua near Hi'ilawe falls in Waipi'o Valley and has served as the caretaker of Koa`ekea which is located in the Waipi'o Valley lookout area owned by the County of Hawaii since 2016. In addition, Pohaha I Ka Lani is also stewarding Mahiki, Kilohana, Waiholoa, and Waikaileo,which total of 2,100+acres in the rimlands of Waipi'o Valley and owned by Kamehameha Schools and Lalakea Trust Fund. 3. Program Description: This program builds upon two decades of Pohaha I Ka Lani's cultural perpetuation and stewardship initiatives in Waipi'o Valley.The program will offer meaningful cultural learning experiences set in the historical and culturally rich wahi pana of Waipi'o Valley while responding to food insecurity and community feeding needs during the COVID-19 pandemic. Observing social distancing protocols,the project will engage beneficiaries in traditional and responsible stewardship practices as well as connect Hawaiians with cultural learning experiences that draw on the'Ike of kupuna, kupa'aina,and mahi'ai;share knowledge of hula, mele, and `olelo Hawai'i about this sacred place;and demonstrate cultural protocols and Hawaiian values.The program emphasizes service-learning and hana no'eau to provide deeper understanding and impact.Since 2001,the applicant's efforts have engaged over 10,000 residents and visitors, resulting in the creation of productive lo'i kalo and traditional agroforestry systems that produce an abundance of edible crops that are harvested and donated to feed many. Food donations are made to volunteers, kupuna, and vulnerable families in the greater Hamakua, Hilo, and Puna regions.The project will expand upon cultural education and land stewardship initiatives in Waipi`o Valley by continuing planting and harvesting of ethnobotanical gardens.The gardens include over a dozen plant species utilized for traditional Hawaiian medicine and food that are planted by personnel and volunteers during malama'aina workdays. The ethnobotanical gardens are used to guide educational workshops that increase the knowledge and skills of practitioners, locals,and visitors about traditional uses of native plants.Since the onset of the COVID-19 pandemic in March 2020,the organization has been unable to host large groups for stewardship and food harvest activities.The organization has focused on community feeding and food distribution in direct response to the public health emergency. During the pandemic, Pohaha I Ka Lani has distributed more than 70,000 lbs.of locally grown produce, in addition to locally grown beef, pork,fish,45,000 hull (taro starts)and other plants,trees, cuttings and seeds to 2,000+vulnerable families on Hawai'i Island.This project will support the continuation of this effort. 4. Total Budget& Position Count: Total Program Budget: $150,000 Total Program Position Count: 1.5 Total Agency Budget: $250,000 Total Agency Position Count: 1.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page2of8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 'Al 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Full Calabash Fund $50,000 Native Voices $20,000 Atherton Family Foundation $20,000 Vibrant Hawaii $10,000 TOTAL: $100,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Pohaha I Ka Lani is a current beneficiary of The Kohala Center's Rural and Cooperative Business Development Services Program, which provides grant writing and funding opportunity identification support to the organization. POI-aha I Ka Lani intends to apply for funding opportunity to the Administration of Native Americans, USDA Local Food Promotion Program, Hawaii Department of Agriculture Microgrants for Food Security Grant Program, Office of Hawaiian Affairs funding programs,and the Native American Agricultural Fund, among other opportunities to secure additional support for this program. Pohaha I Ka Lani previously received$100,000 in funding from the CARES Act to administer emergency community feeding services and is poised to re-apply for these funds,should they become available through future federal stimulus packages.The organization will also solicit in-kind and cash donations from community and business stakeholders with an interest in contributing to the preservation of working agricultural lands in Waipi`o Valley. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objectives for the proposed project include: 1) Perpetuation of Hawaiian culture and food systems through the cultivation of traditional food crops and medicinal plants, including lo`i kalo restoration and cultivation,agroforestry systems and native plantings, invasive species removal, and identification and restoration of ancient sites in Waipi`o Valley 2)Continued service of food insecure communities by harvesting food and medicine from stewarded lands to provide meals,food boxes, plants,trees, plant cuttings,and seeds to a minimum of 200 vulnerable families and kupuna in the Hamakua, North/South Hilo,and Puna communities. 3)Cultural immersion and knowledge exchange with kupa`aina and kupuna through hands-on land stewardship, including learning mele, mo`olelo, and sharing in traditional food and medicine preparation. 4)Continued protection of sacred sites from trespassing and destruction through active stewardship, public education,and ecosystem monitoring. EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page3of8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 'Ai 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens forthe Participants afterthey have participated in your program?Describe,be specific.) Removal of invasive species on 100+acres in Waipi'o Valley and rimlands Activity logs and photographs Planting of 12+native species on 100+acres in Waipi'o Valley and rim lands Activity logs and photographs Minimum of 200 vulnerable families and kupuna served through community food distribution Service roster updated monthly Increase access to traditional Hawaiian food and medicine for under-served communities Service roster and food distribution list updated monthly Collaborate with a minimum of 10 community-based organizations to support stewardship and food distribution Partner roster updated monthly Minimum of 30 community members volunteer to support land stewardship and food distribution Volunteer roster updated monthly Two jobs retained for program personnel Payroll and contractual expenditure records Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages $95,000 $100,000 $41,000 Professional Fees $0 $0 $0 Operations $25,000 $20,000 $0 Supplies $12,000 $8,000 $4,000 Equipment $0 $0 $0 Other: Plant material $2,000 $4,000 $2,000 Other: Equipment rental (wood chipper) $4,000 $4,000 $2,000 Other: Mileage reimbursement $9,000 $4,000 $1,000 Other: Contractual services $33,000 $10,000 $0 Other: TOTAL $180,000 $150,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page4of8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, oradministratorofyour organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ® Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor ▪ The Managing Director ® The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel,ora Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probabilitythat action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance,any conflicts or potential conflicts of interest: ri If no conflicts exist, check here. Pryfrt 01'�t'- ?� Sig -t re of Authorized Person(specifytitle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page 5of8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 'Ai 11. Certification of Understanding (Page 1 of 2) I (we)have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-142.1,Hawai`i County Code,relating toAppropriation of Fu nds to Nonprofit Organizations. I(we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspectanyfacility,equipment,property,orrecords pertinenttothe grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I(we)have the authority and ability to fully administer the program(s)pursuant to law. I (we)understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we)understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and thatwe have full responsibilityto ensure that all documents are complete and accurate prior to submittal. I (we)understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded agrantfromthe CountyofHawai`i,I(we)understand and will complywith the requirement to enroll with Hawai`i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.aov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded agrantfromthe County ofHawai`i,I(we)understand and will complywith the requirement to submita vear-end reportto the County Council within 60 days afterJune 300f the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page6of8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 'Ai 11. Certification of Understanding (Page2of2) If awarded agrantfromthe CountyofHawai`i,I(we)understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I(we)understand thatfailuretosubmitthefinal reportwithin 60 daysofJune 30thshall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation fora minimum of one year or until a written report is submitted to,and accepted by, the council. I(we)understand there is no proyisionforfurthernotification to submitthefinal report.Information and instructions are available at htto://www.hawaiicountv.00v/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,exceptfora maximum ten percent(10%)foradministrative and overhead costs.Anyfunds unused byJune 30,2022 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of youragencv's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds forCapital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. � l/zfs 21 Signa re of Authorized Person Date IrtyaU d ' of l'adl%-i- 1- 14- 144t4 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY2021-2022 Page7of8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Pohaha I Ka Lani Program Name: Mahina 'Ai 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY2020-2021 Page 8of8 Project Vision Hawaii Better Vision for Keiki 219 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki Agency Director: Darrah Kauhane-Floerke Phone No.: (8(b)30fi— 4406 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 23212 Address: City,ST,Zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,s-r,zip Honolulu, HI 9617 Email Address: darrah@projectvisionhawaii.org Fax No.: (8c 5%— 9909 Accountant/CPA: Greg Wong Phone No.: (8 98�— 7680 Firm (if applicable): Hawaii Care Service, LLC Mailing Address: Address: 1460 Hunakai Street#1 city,s-r,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna Q Hamakua ❑■ North Kona 0 South Hilo 0 North Kohala 0 South Kona ❑■ North Hilo El South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 $10,925 $16,625 2. Agency Mission Statement: Project Vision Hawaii (Project Vision) is a locally grown nonprofit organization with a mission to work in partnership with the people of Hawaii to promote health, happiness, and dignity for all. Founded in 2007, Project Vision provides free health and hygiene services, Covid-19 testing and vaccinations, and help with applying for SNAP and MedQuest. In 2020, Executive Director Darrah Kauhane-Floerke led the organization's Covid-19 response, increasing mobile outreach and providing testing and vaccinations for service providers and people experiencing homelessness. Better Vision for Keiki has achieved the following outcomes to date: 1) 39,801 vision screenings and 4,779 eye exams provided to children in Title I schools. 2) 3,563 prescription glasses provided statewide.The program was halted in mid-March due to COVID-19 school closures. 3. Program Description: Better Vision for Keiki is a statewide collaborative project to expand access to vision screenings in public schools and to provide about 6,000 prescription glasses to children who need them.This is a collaborative project involving Project Vision,Vision To Learn and Hawaii State Department of Education (HIDOE). We provide school-wide screenings to all students unless parents specifically opt out. Approximately 18-22%of children screened are referred to VTL for eye exams. If a student needs glasses, the optician helps him/her choose a frame from a selection at the clinic. Looking forward to the 2021-22 school year, we anticipate that school operations will be back to full-time in-person learning. Should this hold true, Better Vision for Keiki projects delivery of 20,000 screenings and 4,400 exams. However, if school closures continue in the coming school year, we will adapt program operations to whatever level is possible. In addition to working with HIDOE, we are reaching out to low-income, subsidized and transitional housing complexes and the communities of un-housed residents. We conducted recent keiki screenings at Salvation Army Kaneohe, Kapilina Beach Homes, and Kahauiki Village. 4.Total Budget& Position Count: Total Program Budget: $141,995 Total Program Position Count: 4 Total Agency Budget: $2,170,000 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application - FY2021-22 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Atherton Family Foundation 16,250 First Hawaiian Bank Foundation 17,250 Harold KL Castle Foundation 16,750 Freeman Foundation 18,000 Kamehameha Schools 30,000 Public Reimbursement-MedQuest 20,000 HI County Grant-in-Aid 25,000 TOTAL: 143,250 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Project Vision and our partner Vision to Learn (VTL) are pursuing sustainability through public reimbursement for services by MedQuest and Children's Health Insurance Program. VTL successfully credentialed as a MedQuest provider group in November 2020, and contracting is completed with HMSA, UnitedHealthcare and Alohacare. We will also seek reimbursement for frames and lenses where available, which may result in MedQuest reimbursements of up to $85,000 in the 2021/22 school year. We are also pursuing unused Children's Health Insurance Program administrative funding,to support students who are uninsured or otherwise unable to bill through MedQuest. Essentially, Hawaii would ask the federal government to use this funding for other health-related purposes, including improving access to student vision care.This funding could also be used to support reimbursement to Project Vision for vision screenings. 7. Program Objectives Using County Nonprofit Grant Program Funds: The following objectives will be achieved in FY 2022: Objective 1: Deliver 20,000 vision screenings (5,000 in Hawaii County)for public school students to identify children who require eye exams. Objective 2: Conduct an estimated 4,400 eye exams (400 in Hawaii County) for referred children. Objective 3: Provide an estimated 3,080 prescription glasses (320 in Hawaii County) to help children achieve their potential in school and in life. Objective 4: Continue to pursue project sustainability through public and private reimbursement for services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Number of vision screenings provided to public school children on Hawaii Island 5,000 Number of children referred to Vision to Learn for eye exams 400 Number of eye exams delivered with prescription glasses provided as needed 320 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 8,000 96,600 12,500 Professional Fees Operations 1,500 9,855 2,000 Supplies 3,125 12,340 3,500 Equipment Other: Vision to Learn - exams and glasses 3,200 22,000 6,000 Other: Travel - Inter-Island 800 1,200 1,000 Other: Other: Other: TOTAL 16,625 141,995 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki W. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel . Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. January 21 , 2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii • Program Name: Better Vision for Keiki 11. Certification of Understanding (Page g ( age 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govgn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 21 , 2021 Signature of Authorized Person Date Darrah Kauhane-Floerke, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii • Program Name: Better Vision for Keiki 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of vision screenings provided to public school children on Hawaii Island 5,000 Number of children referred to Vision to Learn for eye exams 400 Number of eye exams delivered with prescription glasses as needed 320 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 12,500 Professional Fees Operations 2,000 Supplies 3,500 Equipment Other: Vision to Learn - exams arj 6,000 Other: Travel - Inter-Island 1,000 Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 � Project Vision Hawaii HiEHIE - Hawai'i Island 220 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island Agency Director: Darrah Kauhane-Floerke Phone No.: (80;93016— 4406 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 23212 Address: City,s-r,zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,ST,zip Honolulu, HI 9617 Email Address: darrah@projectvisionhawaii.org Fax No.: (8Q6 58— 9909 Accountant/CPA: Greg Wong Phone No.: (8(J — 7680 Firm (if applicable): Hawaii Care Service, LLC Mailing Address: Address: 1460 Hunakai Street#1 city,sr,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua 0 North Kona 0 South Hilo • North Kohala ❑■ South Kona Q North Hilo Q South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑I■ Youth ❑Victims of Crimes ❑ Culture and the arts ❑� Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor 0 Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 $13,875 $14,375 2.Agency Mission Statement: Project Vision Hawaii (Project Vision) is a locally grown nonprofit organization with a mission to work in partnership with the people of Hawaii to promote health, happiness, and dignity for all. Recent accomplishments include: - Our statewide vision program for public school students has vision-screened 39,801 keiki, conducted 4,779 eye exams, and provided 3,563 free prescription glasses to help children achieve their potential in school. -Continued growth of HiEHiE, bringing hot showers and resources to people experiencing homelessness. In the past 12 months, we provided 3,717 showers at 38 events on O'ahu and Hawaii Island. We are expanding the hygiene program to the island of Kaua'i. - Rapid response to public health challenges of the pandemic with increased services and mobile Covid-19 testing for low-income and homeless individuals and service providers. Since implementing mobile Covid-19 testing in June, Project Vision has conducted more than 5,500 tests for houseless individuals and services providers. 3. Program Description: HiEHiE increases access to care for people most deeply affected by Covid-19, focusing on people experiencing homelessness.The physical and fiscal costs of health care mount for people who lack access to care.Too often, low-income and houseless individuals do not participate in ongoing care, which can result in dire,yet avoidable, consequences. Without preventative, ongoing healthcare, problems become more difficult or impossible to solve. HiEHiE also meets the need for hygiene by bringing mobile shower facilities to locations all over the island.This is needed because going without daily hygiene affects one's mental wellbeing and contributes to the stigma associated with homelessness.The need for hygiene increased with Coivd-19, as washing with soap significantly reduces the risk of many preventable health threats. At each location,the mobile hygiene trailer serves as gathering place, connecting people with services and resources such as onsite screenings,first aid, wound care, referrals, and basic necessities such as dental care supplies, hair care products and hygiene products. 4.Total Budget& Position Count: Total Program Budget: $181,100 Total Program Position Count: 5 Total Agency Budget: $2,170,000 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate CDBG CARES ACT/County of Hawaii(50%of contract funding for program operations) 80,000 Anonymous Donor 20,000 HI County CARES Act 25,000 TOTAL: 125,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Project Vision funds public health outreach through a balance of public and private grants, individual donations, and earned income. We strive for a diverse revenue plan with various types and sources of income.The 2020 operating budget includes corporate and foundation contributions (49%), individual contributions (9%), public grants (40%), and earned income for services (2%). Employing the assets of mobile service units, we pursue public contracts that enable sustainable earned income and align with our mission. For example, Project Vision provides year-round outreach to connect families with the Supplemental Nutritional Assistance Program (SNAP) in Maui County. We have pending contracts with the Department of Health and Kamehameha Schools to provide large-scale Covid-19 testing events. 7. Program Objectives Using County Nonprofit Grant Program Funds: Grant Program funds will be used to achieve the following objectives: Objective 1: Provide 3,000 hot, private showers to people experiencing homelessness. Objective 2: Engage 900 individuals (duplicated) with health and hygiene outreach. Objective 3: Host 36 HiEHiE outreach events on Hawaii Island. Objective 4: Engage 30 community partners in health and hygiene outreach. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Mobile showers provided in Hawaii County 3,000 Individuals experiencing homelessness served(duplicated) 900 HiEHiE outreach events provided in Hawaii County 36 Community partners engaged in health and hygiene outreach 10 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req • Salary and Wages 8,050 155,580 12,500 Professional Fees Operations 1,500 3,000 2,000 Supplies 3,125 13,520 3,500 Equipment Other: Utilities 900 1,800 6,000 Other: Mileage and Parking 800 6,000 1,000 Other: Insurance 1,200 Other: Other: TOTAL 14,375 181,100 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: 1iEHiE - Hawaii Island 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any,conflicts or potential conflicts of interest: n If no conflicts exist, check here. January 21 , 2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island 11. Certification of Understanding (Page sof 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govgn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 21 , 2021 Signature of Authorized Person Date Darrah Kauhane-Floerke, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: HiEHiE - Hawaii Island 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Mobile showers provided in Hawaii County 3,000 Individuals experiencing homelessness served (duplicated) 900 HiEHiE outreach events provided in Hawaii County 36 Community partners engaged in health and hygiene outreach 10 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 12,500 Professional Fees Operations 2,000 Supplies 3,500 Equipment Other: Utilities 6,000 Other: Mileage and Parking 1,000 Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Project Vision Hawaii Hui for Health - Hawai`i Island 221 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island Agency Director: Darrah Kauhane-Floerke Phone No.: (8(j 306— 4406 Contact Person: Same Phone No.: ( ) - Mailing Address: Address: P.O. Box 23212 Address: City,s-r,zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,ST,zip Honolulu, HI 9617 Email Address: darrah@projectvisionhawaii.org Fax No.: (&ej 5*— 9909 Accountant/CPA: Greg Wong Phone No.: (8( 9 — 7680 Firm (if applicable): Hawaii Care Service, LLC Mailing Address: Address: 1460 Hunakai Street#1 City,ST,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna Q Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona 0 North Hilo Q South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $5,925 $13,875 $14,375 2.Agency Mission Statement: Project Vision Hawaii (Project Vision) is a locally grown nonprofit organization with a mission to work in partnership with the people of Hawaii to promote health, happiness, and dignity for all. Recent accomplishments include: -Our statewide vision program for public school students has vision-screened 39,801 keiki, conducted 4,779 eye exams, and provided 3,563 free prescription glasses to help children achieve their potential in school. -Continued growth of HiEHiE, bringing hot showers and resources to people experiencing homelessness. In the past 12 months, we provided 3,717 showers at 38 events on O'ahu and Hawai'i Island. We are expanding the hygiene program to the island of Kauai. - Rapid response to public health challenges of the pandemic with increased services and mobile Covid-19 testing for low-income and homeless individuals and service providers. Since implementing mobile Covid-19 testing in June, Project Vision has conducted more than 5,500 tests for houseless individuals and services providers. 3. Program Description: Project Vision proposes to bring health and human services to the most vulnerable populations on Hawaii Island.Through Hui for Health - Hawaii Island, we are partnering with agencies to bring vision screenings, diabetes screenings, blood pressure tests, Covid tests and vaccines, and other healthcare services to people in need. Vision problems also contribute to difficulties for homeless people and elderly adults. For example, while blindness from diabetes is largely preventable with annual evaluation and treatment, the Hawai'i Diabetes Report estimates that there are up to 29,000 cases of blindness from diabetes each year in Hawaii.Through free, local, accessible vision and retinal screenings, Project Vision is able to help people identify and treat medical problems, including diabetes, glaucoma and macular degeneration. For elderly individuals, poor vision is one of four issues that contribute to falls, which can have a devastating effect on their health and way of life. Falls are the leading cause of both fatal and nonfatal injuries for people over the age of 65. Falls can result in hip fractures, broken bones, and head injuries. Even falls without a major injury can cause an older adult to become fearful or depressed, making it difficult for them to stay active, according to the National Council on Aging. 4.Total Budget& Position Count: Total Program Budget: $76,150 Total Program Position Count: 5 Total Agency Budget: $2,170,000 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Zilber Foundation-unrestricted grant 25,000 Department of Health-fee for services 25,000 HI County GIA 25,000 TOTAL: 75,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Project Vision funds public health outreach through a balance of public and private grants, individual donations, and earned income. We strive for a diverse revenue plan with various types and sources of income.The 2020 operating budget includes corporate and foundation contributions (49%), individual contributions (9%), public grants (40%), and earned income for services (2%). Employing the assets of mobile service units, we pursue public contracts that enable sustainable earned income and align with our mission. For example, Project Vision provides year-round outreach to connect families with the Supplemental Nutritional Assistance Program (SNAP) in Maui County. We have pending contracts with the Department of Health and Kamehameha Schools to provide large-scale Covid-19 testing events. 7. Program Objectives Using County Nonprofit Grant Program Funds: Grant program funds will support the following Hui for Health objectives: 1. Project Vision will provide or partner on 20 Hui for Health events. 2. 450 adults will access vision and health screenings. 3. 200 seniors will access vision and health screenings. This program targets three distinct populations: 1) low-income adults; 2) low-income seniors; and 3) people experiencing homelessness, including adults, seniors and children. We will serve individuals and families who lack health insurance or are under-insured;those living in remote areas, in shelters, or who are unsheltered; and seniors who desire to maintain sufficient health so they can "age in place," and stay in their home as long as possible. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 � Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Hui for Health events on Hawaii Island 20 Number of adults provided vision and health services 450 Number of seniors provided vision and health services 200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req • Salary and Wages 9,500 40,090 18,000 Professional Fees • Operations 1,500 800 2,000 Supplies 2,125 2,400 5,000 Equipment Other: Utilities Other: Mileage and Parking Other: Insurance Other: Other: • TOTAL 13,125 76,150 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefitsaccruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. January 21 2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or • program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. p I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • January 21 , 2021 Signature of Authorized Person Date Darrah Kauhane-Floerke, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Project Vision Hawaii Program Name: Hui for Health - Hawaii Island 12. COUNCIL AWARD WORKSHEET • TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hui for Health events on Hawaii Island 20 Number of adults provided vision and health services 450 Number of seniors provided vision and health services 200 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 18,000 Professional Fees Operations 2,000 Supplies 5,000 Equipment Other: Other: Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Puna Canoe Club Outrigger Paddling Program 222 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:PUNA CANOE CLUB Program Name:OUTRIGGER PADDLING PROGRAM Agency Director: MICHAEL O'SHAUGHNESSY Phone No.:(808 ) 966 —7769 Contact Person: LOUIS MENDONCA Phone No.:(808)961 —6690 Mailing Address: Address: 21 Waianuenue Avenue Address: Suite 2 City,ST,Zip Hilo, Hawaii, 96720 Facility Address: Address: Puna Canoe Club Address: Hilo Bay City,ST,Zip Hilo, HI, 96720 Email Address: punacc@punacanoeclub.org Fax No.: ( ) — Accountant/CPA: Phone No.:( ) — Firm (if applicable): Mailing Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) y Puna Q Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑South Kona El North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑■ Culture and the arts El Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑■ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 1. Prior Year Award of County Nonprofit Grant Program funds: FY 18-19 FY 19-20 FY 20-21 0 0 0 2. Agency Mission Statement: To promote and provide educational opportunities which strengthen family,community,and individuals by providing ocean oriented educational programs, i.e.canoe paddling.Other community improvement educational programs for the youth. Preservation of the Hawaiian culture and traditions as they relate to the ocean. 3. Program Description: Programs include education on history,traditional canoe building and cultural practices associated with outrigger canoe paddling. Fitness training for health,competition and community outreach within all age groups. Upkeep of equipment,i.e. paddles, canoes,trailers. Repair and refurbish traditional outrigger koa canoe,the"Ali'i Kai",quote from Douglas Bumatay in the amount of$ 25,000.00.See attached. Repair and refurbish traditional outrigger koa canoe,the"Kalapana",quote from Douglas Bumatay in the amount of$ 26,500.00.See attached. Canoe trailer quote from Douglas Bumatay in the amount of$24,500.00.See attached. 4.Total Budget& Position Count: Total Program Budget: $ 76,000.00 Total Program Position Count: Unknown Total Agency Budget: Total Agency Position Count: Unknown EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate 2020 donations=$306.43 UNKNOWN AT THIS TIME 2020 Recycled cans=$18.34 UNKNOWN AT THIS TIME 2020 Annual Puna Canoe Club membership dues=$116.80 UNKNOWN AT THIS TIME 2020 International Va'a Federation reimbursements from Puna Canoe Club members=$3,013.00 UNKNOWN AT THIS TIME 2020 Moku of Hawaii Association and Hawaii Canoe Racing Association.reimbursements=$200.00 UNKNOWN AT THIS TIME_ 2020 One man outrigger canoe membership dues=$6,766.88 UNKNOWN AT THIS TIME TOTAL: UNKNOWN AT THIS TIME Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As a result of the covid-19 pandemic Puna Canoe Club has not been able to conduct any fundraisers. It is our understanding that the Hawaii Community Foundation has been selected to administer grant applications for the 2018 Kilauea eruption recovery fund. If so, Puna CC intends to submit an application for any grants available from that grant funding source. 7. Program Objectives Using County Nonprofit Grant Program Funds: Repair and restore Puna Canoe Club's traditional koa canoes-the"Ali'i Kai"and the"Kalapana". Purchase a trailer to transport canoes to and from outrigger canoe races on the west side of the Big Island and to transport canoes to Hilo dock to ship canoes to neighbor islands for outrigger canoe races. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 • Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) The canoe club educated/trained 96 children ages 11 to 17 during the 2019 calendar year. Train and educate as many youths and adults as possible. Volunteer hours for the youth program averaged 6 adults,5 hours per week each for a total of 30 hours per week from March 2019 to July 2019.During the 2019 calendar year,Puna Canoe Club trained/educated 152 adults and 248 children.However,as a result of the Covid 19 pandemic there has been no activity during the 2020 calendar year.When it is safe to do so,Puna Canoe Club plans to train/educate as many youth and adults as possible during the 2021 calendar year. - Attach additional pages as necessary. 9.TABLE II: • PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages None None 0 Professional Fees None None 0 Operations Supplies Equipment Other: Other: Other: • Other: Other: TOTAL *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): pp Y): ❑ Member or members of the Council Di Staff appointed by a member of the Council ❑ The Mayor O The Managing Director O The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: RI If no conflicts exist, check here. Signature of Authorized Person (specify! 1 ,c' C. Date EXHIBIT A NONPROFIT GRANT APPLICATION -FY 2021-2022 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. //.29/ Signature of Authorized Person Date President, Puna Canoe Club Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: PUNA CANOE CLUB Program Name: OUTRIGGER PADDLING PROGRAM 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Salvation Army Family Intervention Services,The Cultural-Based Program - Island-Wide 225 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-Wide Agency Director: Roxanne Costa Phone No.: (808)959— 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,sr,zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808)959— 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808)959—5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 city,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua Q North Kona 0 South Hilo ❑ North Kohala • South Kona UI North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑■ Youth ❑Victims of Crimes 0 Culture and the arts ❑Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-Wide 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 NA NA NA 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed,youth must feel a sense of belonging to their community, their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services(TSA-FIS)Cultural-Based Program provides a safe and nurturing environment along with access to opportunities, experiences, and services to support cultural identity, positive youth development and prevention of risky behaviors. We utilize a prevention approach to address risk factors and increase protective factors. Program services are offered to youth ages 10-21. The main goals of this program are to encourage youth to develop their own sense of cultural idenity, increase their knowledge and skills, and ultimately be able to utilize those skills to help others in their community. Program services include the implementation of our Ahupua'a"From the Mountain to the Sea"curriculum that promotes fundamental life skills through the combination of concepts and skills that have been derived from many different resources. It is also a blending of western and Native Hawaiian practices that teach individuals to navigate the modern world with the same core values that were held by our ancestors. Program acitivities build upon the Ahupua'a curriculum which include skill building opportunites such as basic water safety, First Aid and CPR, environmental conservation, native plant identification, hiking, canoe paddling, life guarding; and education on the fundamentals of safety and preparedness. In additon, youth take part in comunity service learning projects and other activities that increase community connectedness and family strengthening. 4. Total Budget& Position Count: Total Program Budget: 122,000 Total Program Position Count: 7 Total Agency Budget: 4,000,000 Total Agency Position Count: 70 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-Wide • 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Department of Human Services-Office of Youth Services 102,000 County of Hawaii Non-Profit Grant Funds 20,000 TOTAL: 122,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continously explores funding avenues in private, State and Federal sectors to continue and enhance program services. We annually seek grant funds and partnerships to build and extend our program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 50 youth targeted for participation in the Cultural-Based Program island wide,80%will demonstrate an increase in competencies through the Ahupua'a Curriculum. Of the 50 youth, 70%will participate in activities that promote cultural awareness and identity, community service learning projects and social skill building opportunities. Of the 50 youth and their families, 50%will participate in family activities that promote family strengthening and connection to community resources and services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-Wide 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Completion of Ahupua'a Curriculum Program 40 Engagement in Cultural Awareness, Service Learning and Social Skill Building Activities 35 Family Engagement Activities 25 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 70,000 0 Professional Fees 4,400 2,000 Operations 23,000 0 Supplies 12,600 9,600 Equipment 0 0 Other: Program Activities 12,000 8,400 Other: Other: Other: Other: TOTAL NA 122,000 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-wide 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): 0 Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director O The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: a If no conflicts exist, check here. l JAN ® 201 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-Wide ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are p P Y complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded agrant from the Countyof Hawaii I (we) understandand nd will comply with the requirement pY q to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-wide ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I'(we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an • additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions token to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. JAN 2 0 2021 e .' Signature of uthorized Person Date 1v ;io al Commander Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural-Based Program - Island-Wide 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Ahupua'a Curriculum Program 40 Engagement in Cultural Awareness, Service Learning and Social Skill Building Activities 35 Family Engagement Activities 25 • TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 2,000 Operations 0 Supplies 9,600 Equipment 0 • Other: Program Activities 8,400 • Other: Other: Other: Other: TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Salvation Army Family Intervention Services,The Independent Living Skills Program - East Hawaii 226 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii Agency Director: Roxanne Costa Phone No.: (808)959— 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,sr,zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808)959— 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808)959 —5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) • Puna ❑ Hamakua ❑ North Kona ❑■ South Hilo ❑ North Kohala ❑ South Kona 0 North Hilo ❑ South Kohala ❑■ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts ['Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 NA NA 8875.00 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed,youth must feel a sense of belonging to their community, their culture,their peers,and within their families. 3. Program Description: The Independent Living)Skills program is part of the Independent Living Skills-Higher Education-Imua Kakou (IHI) Programs that serve current foster youth,former foster youth, and young adults who have exited out fo the Child Welfare system. The Indepedent Living Skills program serves youth ages 12- 17 and young adults 18-26 and focuses on helping these youth and young adults to develop and acquire vital skills necessary to successfully transition into adulthood. A strength based model is utilized to assess and address the needs of the youth and young adults while working collaboratively with the Department of Education, alternative learning centers,the University of Hawaii system,workforce programs, housing programs,the Family Court Judiciary, Guardian Ad Litems, and other service providers. These partnerships are critical in our efforts to achieve positive outcomes for young people who have experienced foster care. We aim to assist youth and young adults in areas of education, employment readiness,transportation, personal and social skill buiding; and increasing networks of support so they may become empowered to achieve self-sufficiency. Y 4. Total Budget& Position Count: Total Program Budget: 101,038 Total Program Position Count: 7 Total Agency Budget: 4,000,000 Total Agency Position Count: 70 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Department of Human Services-Child Welfare Services East Hawaii Division 91,038 County of Hawaii Non-Profit Grant Funds 10,000 TOTAL: 101,038 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continously explores funding avenues in private, State and Federal sectors to continue and enhance program services. We annually seek grant funds and partnerships to build program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Youth ages 12-17: 1)Engage youth in pro-scoial activiities and skill building sessions that promote positive youth development. 2)Engage youth in community service projects to increase community connectedness and stewardship. 3)Provide educational assistance including tutoring, applying for college and securing financial aid and scholarships. 4)Provide links to other resources and services to best serve the needs of the young people. 5)Offer family strengthening activities to youth and their caregivers. Young Adults ages 18-26: 1)Engage young adults in pro-social activties, community activities, Independent Life Skills sessions,trainings and workshops. 1 2) Provide educational assistance including tutoring, applying for college and securing financial aid and scholarships. 3)Provide links to other resources and supports. 4)Assist young adults to address barriers in areas of:obtaining vital documents(birth certificates, state identification, driver permits/licenses, etc.), medical coverage and services,transporation, housing, accessing parenting classes, employment readiness, and basic needs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of fIawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Completion of Life Skills and Independent Living Skills sessions,trainings and workshops 30 Participate in Pro-Social and Community activities 30 Access resources and services in areas of education,housing,employment,etc. 30 Participate in Follow-up and Monitoring Services 30 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 37,204 65,305 0 Professional Fees 346 11,183 1,420 Operations 7,455 16,807 4,440 Supplies 1,843 3,243 2,400 Equipment 0 0 0 Other: Program Activities 854 4,500 1,740 Other: Actual Expenditures as of 12/31/20 • Other: Other: Other: TOTAL 47,702 101,038 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills - East Hawaii 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ® The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ®° If no conflicts exist, check here. JAN 2 0 2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills - East Hawaii 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:I/www.hawaiicounty.govJfn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Rf JAN 2 0 2021 Signature of Authorized Person Date E'i' is,ona1 Commander mancor Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Life Skills and Independent Living Skills sessions, trainings and workshops 30 Participate in Pro-Social and Community activities 30 Access resources and services in areas of education, housing, employment, etc. 30 Participate in Follow-up and Monitoring Services 30 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,420 Operations 4,440 Supplies 2,400 Equipment 0 Other: Program Activities 1,740 Other: Other: Other: • Other: TOTAL 10,0000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Salvation Army Family Intervention Services,The Kea'au Prevention and Outreach Programs 227 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs Agency Director: Roxanne Costa Phone No.: (808)959— 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,sr,zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808)959— 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808)959—5855 Firm (if applicable): • Mailing Address: Address: P.O. Box 5085 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities • Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $4,800 $5,493 $8,875 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed,youth must feel a sense of belonging to their community, their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services(TSA-FIS)Keaau Prevention and Outreach Programming provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development and prevention of substance use and other risky behaviors. Program services are offered to youth ages 10- 21 and their families residing in the Keaau communities. We utilize a prevention approach to decrease the use and abuse of alcohol,tobacco and other illicit drugs,to prevent involvement in gangs and violence,delinquent behaviors, early sexual behaviors,family conflict, and to improve academic performance and truancy. Program services and activities include the implementation of evidence-based curriculum sessions that promote fundamental life skills, community service learning projects to increase community connectedness;family engagement opportunities to support family strengthening;and cultural-based activities to honor all cultural identities and ensure cultural compentency. 4.Total Budget & Position Count: Total Program Budget: 65,000 Total Program Position Count: 7 Total Agency Budget: 4,000,000 Total Agency Position Count: 70 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs • 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Non-Profit Grant Funds 10,000 Department of Human Services-Office of Youth Services Department of Health-ADAD Substance Abuse Prevention 55,000 Hawaii Community Foundation TOTAL: 65,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continously explores funding avenues in private, State and Federal sectors to continue and enhance program services. We annually seek grant funds and partnerships to build and extend our program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 60 youth targeted for participation in the Prevention and Outreach Programs in Keaau(upper Puna), 80%will demonstrate and increase in competencies through the Botvin Life Skills Training Curriculum and other supplemental curriculums. Of the 60 youth participants,70%will engage in Postive Alternative Activities including cultural awareness,community service learning projects,youth leadership opportunities and peer mentorship. Of the 60 youth participants and their families, 50%will engage in family activities that promote family strengthening and connection to community resources and services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Completion of the Botvin LifeSkills Training Curriculum 48 Participation in Positive Alternative Activities 42 Participation in Family Engagement Activities 30 Follow-up and Monitoring Services 60 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 13,795 30,000 0 Professional Fees 901 6,000 1,300 Operations 3,770 18,600 4,440 Supplies 2,249 8,000 2,460 Equipment 0 0 0 Other: Program Activities 261 2,400 1,800 Other: Actual Expenditures as of 12/31/20 Other: • Other: Other: TOTAL 20,976 65,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 9' If no conflicts exist, check here. r J 42 11 JAN 2 0 2021 Signature uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 , County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Keaau Prevention and Outreach Programs ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 3e shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 ) ,��9����p JAN 2 0 2021 Signature of 'utho sized Person Date Civislonal Commander Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of the Botvin LifeSkills Training Curriculum 48 Participation in Positive Alternative Activities 42 Participation in Family Engagement Activities 30 Follow-up and Monitoring Services 60 • • TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,300 Operations 4,440 Supplies 2,460 Equipment 0 Other: Program Activities 1,800 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Salvation Army Family Intervention Services,The Pahoa Prevention and Outreach Programs 228 i x County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs Agency Director: Roxanne Costa Phone No.: (808)959— 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (8081 959— 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808)959—5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 city,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala Li South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ElYouth ❑ Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises n Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20- 21 $4,800 $5,243 $8,875 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed,youth must feel a sense of belonging to their community,their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services(TSA-FIS)Keaau Prevention and Outreach Programming provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development and prevention of substance use and other risky behaviors. Program services are offered to youth ages 10- 21 and their families residing in the communities of Pahoa. We utilize a prevention approach to decrease the use and abuse of alcohol,tobacco and other illicit drugs,to prevent involvement in gangs and violence, delinquent behaviors, early sexual behaviors, family conflict,and to improve academic performance and truancy. Program services and activities include the implementation of evidence-based curriculum sessions that promote 9 P fundamental life skills,community service learning projects to increase community connectedness;family engagement opportunities to support family strengthening; and cultural-based activities to honor all cultural identities and ensure cultural compentency. 4.Total Budget & Position Count: Total Program Budget: 65,000 Total Program Position Count: 7 Total Agency Budget: 4,000,000 Total Agency Position Count: 70 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Non-Profit Grant Funds 10,000 Department of Human Services-Office of Youth Services Department of Health-ADAD Substance Abuse Prevention 55,000 Hawaii Community Foundation TOTAL: 65,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continously explores funding avenues in private, State and Federal sectors to continue and enhance program services. We annually seek grant funds and partnerships to build and extend our program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 60 youth targeted for participation in the Prevention and Outreach Programs in Pahoa(lower Puna), 80%will demonstrate and increase in competencies through the Botvin Life Skills Training Curriculum and other supplemental curriculums. Of the 60 youth participants, 70%will engage in Postive Alternative Activities including cultural awareness, community service learning projects,youth leadership opportunities and peer mentorship. Of the 60 youth participants and their families, 50%will engage in family activities that promote family strengthening and connection to community resources and services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Completion of the Botvin LifeSkills Training Curriculum 48 Participation in Positive Alternative Activities 42 Participation in Family Engagement Activities 30 Follow-up and Monitoring Services 60 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 13,795 30,000 0 Professional Fees 1,023 6,000 1,300 Operations 3,775 18,600 4,440 Supplies 4,357 8,000 2,460 Equipment 0 0 0 Other: Program Activities 162 2,400 1,800 Other: Actual Expenditures as of 12/31/20 Other: Other: Other: TOTAL 23,112 65,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. � � JAN 2 0 2021 Signature o Auutlforized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs ii.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. JAN 2 0 2021 Signature oebbth rized Person Date Divisional Commander Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of the Botvin LifeSkills Training Curriculum 48 Participation in Positive Alternative Activities 42 Participation in Family Engagement Activities 30 Follow-up and Monitoring Services 60 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,300 Operations 4,440 Supplies 2,460 Equipment 0 Other: Program Activities 1,800 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Salvation Army 7amily Intervention Services,The Project TLP Hilo 229 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo Agency Director: Roxanne Costa Phone No.: (808)959— 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808)959— 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808)959—5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑■ Puna ❑ Hamakua ❑ North Kona ❑■ South Hilo ❑ North Kohala ❑ South Kona ❑■ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ■❑ Educational concerns ❑■ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑■ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 1. Prior Year Award of County Nonprofit Grant Program Funds: FY18-19 FY19-20 FY20- 21 $7300 $6250 $7375 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It us our belief that in order to succeed,youth must feel a sense of belonging to their community,their culture,their peers, and within their families. 3. Program Description: Research has shown that vulnerable young adults,youth transitioning from foster care, and those that are living in unstable situations, comprise of one of the most fast growing groups of homeless individuals. The Salvation Army- Family Interventions Services is determined to help these young adults to overcome such barriers. We aim to stabilize, house,educate,and empower them to thrive and become self-sufficient. With the support and collaboration of our local programs, agencies, Realtors, rental agents, and private landlords,we will be able to help our young people get a fresh start in their lives. Project TLP will be the responsible agent for these young adults by subsidizing the rental fee for those who are eligible for a six month period. Based on extenuating circumstances, rental periods may be extended as needed. With our support they will learn simple strategies such as: balancing a check book,writing a resume,finding employment,time management, signing a rental agreement, and setting and keeping realistic goals for themselves to help with their transition to independence. Should issues arise, program participants will be referred to the appropriate resources/services and given opportunities to address issues and concerns as needed. Project TLP's main objective is to help these young adults achieve their short and long-term goals for sustainable housing. 4.Total Budget & Position Count: Total Program Budget: 85,000 Total Program Position Count: 7 Total Agency Budget: 4,000,000 Total Agency Position Count: 70 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2O21-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii Non-Profit Grant Funds 10,000 Victoria add Bradley Geist Foundation 75,000 Private Donor TOTAL: 85,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in private, State and Federal sectors to continue and enhance program services. We annually seek grant funds and partnerships to build program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. We have also been fortunate to have developed a partnership at the end of 2018 with a private donor who has been very interested in this program and helping the young people we are committed to serving. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Be able to connect young adults with the proper resources and services that they may need. 2)Provide links to resources in areas of continuing education and/or employment. 3)Provide young adults with employment attire,food, hygiene products, and housing starter kits(kitchenware,towels, blankets, etc.)as needed. 4)To promote awareness in the housing community of the struggles that former foster youth encounter in obtaining appropriate housing. 5) Establish collaborative relationships with realty companies and private landlords in the community to provide appropriate housing for participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Flawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) • Completion of Financial Literacy Curriculum 4 participants Participate in Weekly or Bi-Weekly Individual Meetings with Case Worker 4 participants Participate in Follow-up and Monitoring Services 4 participants Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 2,831 24,150 0 Professional Fees 81 380 80 Operations 3,047 14,000 3,150 Supplies • 1,359 1,920 720 Equipment 0 0 0 Other: Program Activities 8,447 44,550 6,050 Other: Actual Expenditures as of 12/31/20 Other: Other: Other: TOTAL 15,765 85,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, anyconflicts gpp co I cts or potential conflicts of interest: If no conflicts exist,check here: �Cl� / JAN 2 0 2021 eril1I L1 4 Signature of AuthorizedlPerson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo si. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.eov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. WA/A.. JAN 2 0 2021 Signature off Authorized Person gDate Divisional Commander Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of FIawai`i Nonprofit Grant Application FY2021-22 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Financial Literacy Curriculum 4 participants Participate in Weekly or Bi-Weekly Individual Meetings with Case Worker 4 participants Participate in Follow-up and Monitoring Services 4 participants TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 80 Operations 3,150 Supplies 720 Equipment 0 Other: Program Activities 6,050 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Services for Seniors [Inc Services for Seniors 230 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Services for Seniors Inc Program Name:Services for Seniors Agency Director: Roxy Salvador and Michelle Yamasaki Phone No.:(808 )935 —1144 Contact Person: Jacqueline Gardner Phone No.:(808)982 --7809 Mailing Address: Address: 99.Aupuni St. Suite 120 Address: City,ST,Zip Hilo,Hi 96720 Facility Address: Address: 99 Aupuni St. Suite 120 Address:. City,ST,Zip Hilo,Hi 96720 Email Address: jgardner14@hawaii.rr.com Fax No.: (808 ) 935 —1143 Accountant/CPA Yvonne Egdamin Phone No.:(808) 935 —3337 Firm (if applicable): Egdamin, Hu CPA, Inc. Mailing Address: Address: 688 Kinoole Street#121 City,ST,Zip Hilo,Hi 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 75,000.00 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona 0 North Hilo 0 South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth 0 Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawvai`i Nonprofit Grant Application FY2021-22 Agency Name: Services for Seniors Inc Program Name: Services for Seniors 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 0 0 0 2.Agency Mission Statement: Services for Seniors(SFS)provides in home Case Management to frail elders age 60 and older to address and assist with their needs to remain at home as long as possible.The goal is,and has always been,to keep the clients in their own homes for as long as possible,linking them to the all of the appropriate community resources without the client/caregiver having to go through repeated steps to meet every unmet need.Maximizing the efficient and appropriate utilization of community resources,in a manner that provides excellent quality and timely care. 3. Program Description: Services for.Seniors,Inc.,(SFS) service component is Case Management,and our goal is to help clients,families and/or caregivers to engage in a problem-solving process of identifying needs,exploring options,and mobilizing informal as well as formal supports to achieve the highest possible level of client independence,along with monitoring and providing follow-up and reassessment as needed.Assistance includes assessing needs,developing care plans,implementing care plans,providing service linkage to Personal Care,Day Care,Homemaker services,Heavy Chore,Assisted Transportation,Attendant Care,Nutrition and Home-Delivered Meals as necessary to meet the long term needs of frail, homebound adults to improve their quality of life,self-sufficiency,and ability to remain in their homes for as long as possible. Transportation has always proven to be a major hurdle to remaining independent for seniors.The Hawaii County Non-Profit Grant will allow SFS to contract with more providers focusing on increasing availability of Assisted Transportation and purchasing necessary home safety equipment not covered by most medical insurance. To implement the plan,SFS will provide information and assistance,coordinate existing services and/or order provider services as necessary,monitor the service delivery,reconcile service orders to service payment,and monitor the status of the client and caregiver.SFS does not provide direct services to the client,only case management;therefore,there is no potential for conflicts of interest.Service covers the entire County of Hawaii.The office hours are 7:45 am to 4:30 pm. Mondays through Fridays,not including holidays. 4.Total Budget&Position Count: Total Program Budget: 75,000.00 Total Program Position Count: 1.5 Total Agency Budget: 250,000.00 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Services for Seniors Inc Program Name: Services for Seniors dossmassommianwilummomp 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Small Business Administration Paycheck Protection Program 10,000.00 Kupuna Grant Program 10,000.00 TOTAL: 10,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: With increased funding the agency would be able to hire and pay a Case Manager for one year.This would increase client load and increase billing hours and decrease if not eliminate the waiting list for services.One full time Case Manager is able to bill an estimated eight thousand($8000.00)service units monthly to the Kupuna Grant Program. 7.Program Objectives Using County Nonprofit Grant Program Funds: The program objective using County Funds is to build SFS capacity to service more clients and decrease the Office of Aging wait list by permitting hiring of 1 additional Case Manager.One Case Manager can usually manage 20-30 clients, depending on complexity. This increase in staffing will decrease the ongoing queue of 20-30 seniors waiting for services. The Hawaii County Nonprofit Grant will also allow SFS to purchase home safety equipment not covered elsewhere which will decrease chances of clients falling and subsequent hospitalizations. By having money available to contract with established transportation providers seniors can obtain medication in a timely manner,go to their doctor appointments, and grocery shop safely and independently. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of I Iawai i Nonprofit Grant Application FY2021-22 Agency Name:Services for Seniors Inc Program-Name:Services for Seniors 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants afterthey hove participated in your program?Describe,be specific.) With a random client survey of 25%of dients enrolled Clients feel their care needs were met by the Services for Seniors program 100%will feel satisfied by the program Clients and/or caregivers participated in the development of the care plan 100%will agree they were a part of the care plan Clients were able to remain in their homes for at least three months 80%will be in their homes at the end of three months Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget . Grant Req Salary,and Wages 38,059.38 57,088.00 57,088.00 Professional Fees Operations 912.00 912.00 Supplies 'Equipment 17,000.00 17;000:00 Other: Other: Other: Other: Other: TOTAL 38;059.38 75,000.00 75,000:00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Services for Seniors Inc Program Name:Services for Seniors 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Services for Seniors Inc. POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 Member or members of the Council ® Staff appointed by a member of the Council The Mayor El The Managing Director O The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 0a If no conflicts exist,check here. rte P", Se1. 0' /� a® Sign iere of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Services for Seniors Inc Program Name:Services for Seniors NiwmpmwmEiwawmmmmmmnmmwvmiw is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records,reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the programs) pursuant to law. I(we)understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii,I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,and accurate year-end report, usinq the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Services for Seniors Inc Program Name:Services for Seniors ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawalicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Sig d#re of Authorized Person Date Ct r'- 1 , Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name:Services for Seniors Inc Program Name:Services for Seniors Nrimmimanammr 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result With a random client survey of 25%of clients enrolled Clients feel their care needs were met by the Services for Seniors program 100%wID tem satisiedbY hepogram Clients and/or caregivers participated in the development of the care plan Clients were able to remain in their homes for at least three months TABLE II: FY PROGRAM EXPENDITURES 21-22 Council Grant Request Award Salary and Wages 57,088.00 Professional Fees Operations 912.00 Supplies Equipment 17,000.00 Other: Other_ Other: Other: Other: TOTAL 75,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Society for Kona's Education & Art (SKEA) Art Camps for Children and Teens 231 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: Art Camps for Children and Teens Agency Director: Susan B. Rice Phone No.:( 808) 328 - 9392 Contact Person: Susan B. Rice Phone No.:( 808)896 - 5858 Mailing Address: Address: P® Box 256 Address: City,ST,Zip Honaunau,Hawaii 96726 Facility Address: Address: 84-5191 Mamalahoa Highway Address: City,ST,Zip Honaunau, Hawaii 96726 Email Address: susanrice@hawaii.rr.com Fax No.: ( ) - Accountant/CPA: Eric Curtis Phone No.:( 808) 322_ 0055 Firm (if applicable): Tax Partners Mailing Address: Address: PO Box 230 City,ST,Zip Kealakekua,Hawaii 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $11,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns XIX Youth ❑Victims of Crimes l'iN Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art Program Name: Art Camps for Children and Teens 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $4,925 I $7,415 $6,800 2.Agency Mission Statement: Mission: With a focus on South Kona, the Society for Kona's Education and Art serves the people of Hawai'i Island by providing arts and educational opportunities through programs,projects, and events that contribute to a vibrant community. Vision: Enhancing lives through creativity and knowledge. The Society for Kona's Education&Art(SKEA) is a 501c3 community organization in South Kona, founded in 1981 by a group of young families who wished to provide education in the arts for their own and others' children. SKEA owns a .75 KSBE lease in Honaunau which includes two historic buildings that provide space for the office,pottery studio, and two large rooms for classes, art camps, and community events. An active Board of Directors meets monthly and volunteer their time and expertise on a regular basis. The part-time staff(executive director and Art Camp Director) are experienced in their position with SKEA, and have contacts with many artists in the community who are experienced teachers in their medium. 3. Program Description: and§KEA will offer day camps in the visual and performing arts during the fall, spring, and summer school breaks. Dates are one week in October 2021, one week in March 2022, and three weeks in June 2022, from 8:30am-1:45 pm, for a total of 25 days of camp. The camps provide a fun learning experience in the arts for children ages 6-11, taught by experienced teaching artists. The curriculum includes a wide variety of activities such as painting and drawing, collage,mixed media, pottery, dance, creative movement, music, theatre arts,magic, and yard games. High School students are hired and trained to act as counselors and teaching assistants; the onsite supervisor is a DOE teacher; teaching artists are experienced as well. The quality of instruction is high and the students are able to produce an excellent body of work that is on display at the end-of-camp performance. We have purchased a large, sturdy tent and will use that for outdoor classes until it is safe to be inside.We will follow all of the County and State guidelines.At this time we are planning to have 10 students at a time on site for the Spring 2021 camp. 4.Total Budget&Position Count: Total Program Budget: $37,625 Total Program Position Count: 10+ Total Agency Budget: $120,000 Total Agency Position Count: 3 pant time EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: Art Camps for Children and Teens 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Tuitions $ 14,000 Kukio Community fund 5,000 State Foundation on Culture and the Arts 2,000 Kona Brewers Festival 2,000 Rotary Club of Kona Mauka 1,000 all of the above have been awarded in the past. TOTAL: $24,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to seek other funding from private Hawaii foundations and individual donors. The tuition for the camps is very reasonable, but it is still a hardship for many families in our rural community. We therefore are committed to keeping the tuition at the current rate. We solicit scholarship donations so that we are able to offer generous donations. For the 3 week summer camp, we would like to offer one week as a stand alone program, and the subsequent two weeks camp could be taken together.This allows for more in-depth art projects, high fired pottery, and rehearsal time for the performance. However, it depends on what the health guidelines are at that time. We will try to accomodate as many children as possible while keeping everyone safe and keeping the activities engaging and meaningful.The big tent that we have now will help, and so will creative scheduling. Our organization does a lot of fundraising each year to support our programs, and we will continue to do so. 7. Program Objectives Using County Nonprofit Grant Program Funds: Art Camps and Teen Counselor Program Objectives: • Expose students ages 6-18 to the arts and to working artists and their materials, improving their artistic skills and knowledge, and stimulating creative thinking and communication. • Provide meaningful work experience to teens ages 16-19 in our community, giving our young people the opportunity to learn responsibility, cooperation, organization, as well as providing specific job skills and monetary compensation. • Increase poise and confidence through dance, movement, and theatre arts culminating with an end-of-camp performance. • Increase the availability of culturally enriching activities for children and young people in our community. * Provide opportunities for artists in our community to share their skills. * Provide a safe venue for fun, healthy, and educational activity during the school breaks. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children and Teens 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES Projected results (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) attendance-this will depend on health guidelines 20+students per session were students engaged?amount and qulaity of work on display yes, high quality work Performance-did everyone perform? appear confident?know their lines and routines? yes, yes, and yes Level of engagement during class students are quietly focused did students finish their work?did they display pride or disappointment in their work yes, and they were proud � I I Attach additional pages as necessary. 9.TABLE II: FY PROGRAM EXPENDITURES 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 0 0 Professional Fees $16, 175 5,000 Operations $6,250 in-kind Supplies 2,800 1,000 Equipment 0 0 Other: registrations, administration 2,400 500 Other: teen counselors 8,750 3,500 Other: hospitality 250 0 Other: marketing 1,000 Other: 1,000 we are planning for 2021 Spring and Summer camps TOTAL 0 $37,625 $11,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑XX If no conflicts exist, check here. Susan ' E' Digitally signed by Susan Rice Date:2021.01.2713:44:22-10'00' y Januar 27, 2021 �.7 �7 1 1 Rice l Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona' s Education & Art (SKEA) Program Name: Art Camps for Children and Teens 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children and Teens 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. • By signing below,you are acknowledging that you have read and understood these requirements. Susan Rice Digitally signed by Susan Rice January 27, 2021 Date:2021.01.2713:37:06-10'00' Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: I I FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary Wages es g Professional Fees • Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Society for Kona's Education & Art (SKEA) South Kona Workshops and Events 232 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Society for Kona's Education & Art (SKEA) Program Name:South Kona Workshops and Events Agency Director: Susan B. Rice Phone No.:(808 ) 328 —9392 Contact Person: Susan B. Rice Phone No.:(808 )896 —5858 Mailing Address: Address: PO Box 256 Address: City,ST,Zip Honaunau, Hawaii 96726 Facility Address: Address: 84-5191 Mamalahoa Highway Address: City,sr,zip Honaunau, Hawaii 96726 Email Address: susanrice@hawaiisr.com Fax No.: ( ) — Accountant/CPA: Eric Curtis Phone No.:(808) 322 —0055 Firm (if applicable): Tax Partners Mailing Address: Address: PO Box 230 City,ST,Zip Kealakekua, Hawaii 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ■❑ North Kona ❑South Hilo ❑ North Kohala Q South Kona ❑ North Hilo ❑South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns g Youth ❑Victims of Crimes ❑■ Culture and the arts g Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 4,250 4,250 3,425 2.Agency Mission Statement: Mission: With a focus on South Kona,the Society for Kona's Education&Art(SKEA)serves the people of Hawaii Island by providing arts and educational opportunities through programs,projects,and events that contribute to a vibrant community. Vision: Enhancing lives through creativity and knowledge. The Society for Kona's Education&Art(SKEA)is a 501 c3 community organization in South Kona,founded in 1981 by a group of young families who wished to provide education in the arts for their own and others'children.SKEA owns a.75 KSBE lease in Honaunau which includes two historic buildings that provide space for the office,pottery studio,and two large rooms for classes,art camps,and community events.We have purchased a large,sturdy tent for the yard and we will hold small workshops and classes, under the tent until it is safe to be indoors. We will observe all of the current guidelines from the County and the Dept.of Health.We will plan our regular events,and hope that we may be able to gather in larger groups during the 2021-2022 FY. An active Board of Directors meets monthly and volunteer their time and expertise on a regular basis.The part-time staff (executive director,event coordinator/art camp director)are experienced in their position with SKEA,and have contacts with many artists in the community. 3. Program Description: Through funding from the County of Hawai'I, SKEA has offered a variety of workshops that appeal to a broad range of interests. Before the pandemic,the response had been overwhelmingly positive,every workshop had been well attended. Participants have been mostly seniors(50+),but also some younger adults and children and adolescents,accompanied I by a parent or grandparent.The workshop fees are VERY reasonable,and we feel this is a crucial element of success in this rural community. People are able to leave 3 hours later with a beautiful,handmade item,or new knowledge of a subject or art medium that is of interest. see attached 4.Total Budget& Position Count: Total Program Budget: $17,150 Total Program Position Count: 10+ instructors Total Agency Budget: $i20,000 Total Agency Position Count: 3 part-time EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 PROGRAM DESCRIPTION: South Kona Workshops&Events 2021-2022 Through funding from the County of Hawaii, SKEA has offered a variety of workshops that appeal to a broad range of interests.Before the pandemic,the response had been overwhelmingly positive, every workshop had been well attended. Participants have been mostly seniors (50+),but also some younger adults and children and adolescents,accompanied by a parent or grandparent The workshop fees are very reasonable,and we feel this is a crucial element of success in this rural community. Botanical Drawing and Painting and Oil Painting workshops will be two-day weekend events. Pottery will be multi- day workshops.We will choose from the following list of possibilities: Figure Painting August 2021 (6 instructor hrs.) Some of these are popular workshops Photography-July 2021 (3 hrs) that we have offered in the past,and Oil Painting-July 2021 (12 hrs) some are new workshops,but all of the Pottery(1 adults and lchildren)-July-Sept. 2021 (18 hrs) ones listed have a known qualified Botanical Art- 2 weekends, October 2021 (marketing only) instructor available.We are proposing Gourd Design- October 2021 (3 hrs) 16 workshops with a total of 72 hours Mushroom Cultivation- November 2021 (3 hrs.) of instruction. Origami March 2022 (3 hrs.) Wreathmaking- December 2021 (3 hrs) We have purchased a large,sturdy tent Handmade Books January 2022 (3 hrs) and plan to hold small workshops that Coconut baskets- February 2022 (3 hrs) follow all guidelines as to number of Watercolor Flowers April 2022 (6 hrs) participants (as of this writing,no more Lei Making- May,2022 (3 hrs) than 10),masks,and social distancing. Hawaiian Quilting February, 2022 (3 hrs) Gyotaku-January 2022 (3 hrs.) When the pandemic subsides,we will resume events; we are planning for 5. We hire talented practioners in each field who also have good teaching skills.Marketing each workshop will be done through our newsletter,posters,press releases to newspapers and radio, email marketing,social media, our roadside sign, and some paid advertising. SKEA offers the community several free or very low-cost events throughout the year,that are attended by residents and also visitors. Music on the Lawn- October,2021;Local musicians will play a variety of songs in different genres, with the last hour being kanikapila. $8 donation requested. Annual Membership Meeting-January,2022 An afternoon of live local music,pupus,and a showing of local art.The SKEA Board is introduced and we update guests on SKEA's programs at a short meeting.A kanikapila ends the afternoon. Free and open to the public. South Kona Studio Tour-in association with the South Kona Artists Cooperative,SKEA will host 3 or 4 South Kona artists at our site.February, 2022 Quilt Show- 2nd weekend in February,2022.A beautiful display of locally made quilts in a variety of styles. Mauka Talent Show June, 2022. A family entertainment variety show of local performers of all ages, preschool to seniors.$7 donation. Artists,performers,and musicians donate their time for these events,and volunteers help with the activities on the day of the event Marketing expenses include paid advertising,posters,flyers, roadside signs,web calendars, email marketing,newspaper notices and feature articles. Outcomes: 1.we expect that a total of 10 people will attend each workshop. Events are still a maybe.If we are unable to have events,then we will use the County funding for more workshops. 2.Residents and visitors from around the island will visit South Kona and enjoy its scenic beauty,restaurants,and other cultural sites. 3. Local artists will be supported and recognized.4.The SKEA organization will make new friends and supporters in the community and connect with old ones. County of Hawai`i Nonprofit Grant Application FY2O21-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate workshop tuitions 10 workshops x10 people x$20 tuition 2,000 workshops tuitions 10 workshops x 10 people x$30 tuition 3,000 ticket sales for 2 events(3 events are free) 2,000 TOTAL: 7,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to work with community volunteers and other groups and organizations(e.g.the South Kona Artists Cooperative)in bringing high quality workshops and events to South Kona.We may also write proposals to individuals and foundations that are interested in the arts.the SKEA Board and other volunteers will continue with fundraising activities to help pay for site expenses and other program expenses.We will maintain our connection with volunteer helpers,who are a huge help in setting up and running events,and with artists and performers,who often donate their services. 7. Program Objectives Using County Nonprofit Grant Program Funds: Workshop Objectives: *To give the opportunity for creative expression to people in our community,especially seniors. *To encourage the use of natural materials in making beautiful things. *To provide new knowledge in the areas of agriculture an art *To engage in social interaction(as allowed by the County and State guidelines) *To educate participants on environmental stewardship(e.g.the ban on picking and transporting ohia.) Event Objectives: *To create and implement a comprehensive marketing plan for each event. *To showcase local art,artists,and performers and develop the community of south Kona as a destination for cultural events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) number of workshop participants 10 people x 16 workshops 160 participants number of event attendees 5 events x 100 attendees 500 (expecting smaller than usual attendance due to leftover pandemic caution,if indeed we are even able to hold large gatherings.) volunteer hours-tent setup,food donations,artist,performers,clean-up (80 hrs x 5 events) 400 volunteer hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 20-21 FY21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees $600 $4,100 3,000 Operations $1,000 0 Supplies $ 2,250 2,000 Equipment 500 0 Other: marketing $750 $ 5,250 3,000 Other: workshops registrations and coordination 2,250 1,000 Other: events (5) coordination & setup $ 1,500 1,000 Other: hospitality 300 0 Other: figures in column 1 are as of January 2021. TOTAL $1,350 $17,150 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ® The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ID If no conflicts exist, check here. Susan Rice Digitally signed by Susan Rice Date:2021.01.2712:44:17-10'00' January 27, 2021 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: South Kona Workshops and Events 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Susan Rice Digitally signed y Susan Rice Date:2021012712:4535 10'00' January 27, 2021 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result � I TABLE II: FY 21-22 r Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: • Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Special Olympics Hawai'i Special Olympics East Hawai'i 233 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Special Olympics Hawaii Program Name:Special Olympics East Hawaii Agency Director: Dan Epstein Phone No.:(808 )943 —8808 ext 26 Contact Person: JaNeal Stevens Phone No.:(360)490 -2610 Mailing Address: Address: PO Box 7265 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 91-610 Maunakapu Street Address: City,sr,Zip Eva Beach, HI 96707 Email Address: EastHawaiiAD a§sohawaii.org Fax No.: ( ) — Accountant/CPA: Akamine, Oyadomari & Kosaki Phone No.:(808) 941 —0500 Firm (if applicable): Akamine, Oyadomari& Kosaki Mailing Address: Address: 1440 Kapiolani Street #900 City,sr,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Q Hamakua ❑North Kona 0 South Hilo ❑North Kohala ❑South Kona Q North Hilo ❑South Kohala Q Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged Q Victims of Health or Social Crises ❑ Needs of the poor '0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment - r EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $16,808 $ 11 ,775 $12,000 2.Agency Mission Statement: The mission of Special Olympics is to provide year-round sports training and athletic competition in a variety of Olympic-type sports for children and adults with intellectual disabilities,giving them continuing opportunities to develop physical fitness,demonstrate courage,experience joy and participate in a sharing of gifts,skills,and friendship with their families,other Special Olympics athletes and the community. 3. Program Description: Special Olympics Hawaii—East Hawaii Area program is open to everyone with intellectual disabilities in Hawaii, regardless of the extent of their disability or their age.Special Olympics believes that all people,regardless of their disability deserve to lead full,active lives,enriched with social and recreational opportunities that most of us take for granted. 2020 highlighted the value of social interaction and relationships.With COVID-19"social distancing"mandates, put everyone in a state of isolation,giving many the first taste of how it feels to be isolated and lonely. I believe now more than ever,the Social nourishment,that Special Olympics provides to our most vulnerable population,can be fully appreciated. In addition to a safe,supportive and nurturing environment,Special Olympics is tailored to the Success of our Athletes. Everyone's able to compete in a variety of sports with other's who match their ability;providing for many the only opportunity to"play on equal ground"with their contemporaries.There is never a fee to any athlete or their family to participate in our program.All Athletes receive meals at competitions,ribbons/medals,transportation and uniforms free of cost. The East Hawaii program off'er's the only school program for students with an intellectual disability on Big Island, collaborating with Hilo High,Waiakea High and Pahoa High school and Laupahoehoe Charter School,in addition we have partnered with After School All Stars and provide an inclusionary sports program for Kea'au,Pahoa and Kau Intermediate schools.The geographical area that makes up East Hawaii is North Kohala,Waimea,Honokaa,Hilo,Pahoa and Kea'au all the way to Kau,which constitutes the largest reach on the island. 4.Total Budget&Position Count: Total Program Budget: $64,500 Total Program Position Count: Total Agency Budget: $2,138,055 Total Agency Position Count: 12PT 10FT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii S.Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate County of Hawaii $15,000 Fundraisers $42,500 Grants $2000 Individual donations $4500 SOHI Airfare fund $500 TOTAL $64,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Due to the unprecedented crisis of 2020,we had to put many of our fundraisers on pause. Cop on Top and Tip a Cop were some of our largest fundraisers that we were unable to hold due to COVID-19 restrictions. We are hopeful by the Fall of 2021 we can resume these community based fundraisers. We have also modified fundraisers such as our Zumbathon,doing it virtually instead of in-person.Despite the pandemic we continue to receive individual donations.The Area Director continues to look for new ways to raise money within the current constraints. 7.Program Objectives Using County Nonprofit Grant Program Funds: With COVID-19 still directing how life proceeds,we will continue to provide quality Virtual sports training and competitions to all active Athletes within East Hawaii. This modification was developed at the beginning of the pandemic and we had amazing results from every Athlete who participated.Grant money will be utilized to pay for medals,ribbons,lei's and postage for these Virtual Competitions.Once Special Olympics North America provides clearance to offer in-person practices and competitions,our goal is to offer Physical competitions in the Fall of 2021 and resume our regular season beginning January 2022. With this as our expectation,funds from this grant will also be utilized to support these local and State competitions and practices. PPE will be purchased to ensure the safety of our Athletes,Volunteers,Families and staff. We are excited to Re-engage our Unified Champion Schools program,due to COVID-19 we have launched an incentive based Walking Program,which allows Special Education students and Regular Ed students a chance to interact and remain socially distant,all while improving their fitness. Two storage units are required to safely house all supplies and equipment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 4 � County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) Special Olympics Athletes on Island and air-travel for Area and State Competition:Improves fitness,nurtures social health.Pride Athlete driven fundraisers:Encourages our Athletes to strengthen life skills"i.e.Communication,Responsibility,Math Volunteer Engagement Cultivates community Compassion and Contribution Unified Champion Schools:Develops acceptance amongst our youth,and encourages inclusion Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 15,000 15,000 Professional Fees Operations 6349 7700 2000 Supplies 4000 5000 1500 Equipment 5500 4300 2500 Other: Airfare for Athletes competing at State level $0 20,000 2500 Other: Area competitions/practices/fundraisers on Island $4000 10,000 5000 Other: Volunteer Engagement and Support $1000 2500 1500 Other: Other: TOTAL 35,849 64,500 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Special Olympics Hawaii Program Name:Special Olympics East Hawaii 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ® Staff appointed by a member of the Council ® The Mayor • ® The Managing Director ® The Director of Finance ® The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: ❑) If no conflicts exist,check here: C S,DE.-p14 tez t/ Signature of Authorized n(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii 11.Certification of Understanding (Page 1 of 2) I (we)have read and understood all of the eligibility requirements;grant conditions;award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s)pursuant to law. I (we)understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I(we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we)understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i,I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii,I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:Special Olympics Hawaii Program Name: Special Olympics East Hawaii 11.Certification of Understanding(Page 2 of 2) If awarded a grant from the County of Hawaii,I(we)understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I(we)understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to.and accented by.the council. I(we)understand there is no provision for further notification to submit the final report.Information and instructions are available at htto://www.hawaiicountv.gov/fn-nonorofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2022 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's futurefundinq request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. fl S� ature of Authorizd'd Person Date President and CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Special Olympics Athletes- Area and State Competitions: Athlete driven fundraisers: Encourages our Athletes to strengthen life skills" fonm tagalR W161Y.M.h Volunteer Engagement: Unified Champion Schools: TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 2000 Supplies 1500 Equipment 2500 Other: Airfare for Athletes State Co 2500 Other: Area Competifion/Practices 5000 Other: Volunteer Engagement 1500 Other: Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Special Olympics vv ins Haai i p Y p Special Olympics West Hawai'i 234 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: SPECIAL OLYMPICS WEST HAWAII Agency Director: Dan Epstein Phone No.:(808 )531 —1888 Contact Person: Denise Lindsey Phone No.:(808 )345 —0433 Mailing Address: Address: P.O. Box 390358 Address: City,ST,Zip KEAUHOU-KONA, HI.967`39 Facility Address: Address: 1833 KALAKAUAAVE,SUITE#500 Address: City,ST,Zip HONOLULU, HI.96815 Email Address: sowhdenise@gmail.com Fax No.: (808 ) 345 —0433 Accountant/CPA: Akamine, Oyadomari & Kosaki Phone No.:(808 ) 941 —0500 Firm (if applicable): Mailing Address: Address: 1440 Kapiolani Blvd.#900 City,ST,Zip Honolulu, Hawaii.96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna [] Hamakua 0 North Kona ❑South Hilo ❑■ North Kohala g South Kona El North Hilo ❑South Kohala ■❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns g Youth ❑Victims of Crimes ❑ Culture and the arts ❑� Aged ❑Victims of Health or Social Crises ❑ Needs of the poor I Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: •°c'6'( 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 11375.00 18159.00 11125.00 2.Agency Mission Statement: The mission of Special Olympics is to provide year round sports training and athletic competition in a variety of Olympic type sports for children and adults with intellectual disabilities,giving them continuing opportunities to develop physical fitness,demonstrate courage, experience joy and participate in a a sharing of gifts,skills,and friendship with their families, other Special Olympics athletes and the community. 3. Program Description: With COVID-19 underneath our belt,we are still able to offer Special Olympics Athletes training and competition in a variety of sports,virtually. We anticipate hopefully sooner than later to get back outdoors. With that being said,we offer 9 sports for our athletes to train and compete locally. We also travel 3 times per year for State Games. We offer Unified Sports in track and field,softball,soccer,bocce ball and bowling. Unified Sports allows athletes with intellectual disabilities to train and compete together with persons without ID,they are called Special Partners. 4.Total Budget&Position Count: Total Program Budget: 49196.00 Total Program Position Count: 1 Total Agency Budget: 2,138,55.00 Total Agency Position Count: PTS&,o EXHIBIT A County of Hawaii Nonprofit Grant Application FY 2021-22 Program Funding Sources (Continued) Hilton Christmas Crafts Fair 2500.00 Virtual Auction 1000.00 virtual Run/Walk 1000.00 Bowling Fundraiser 1000.00 Golf Tournament 6200.00 Kona Marathon 1000.00 Lavaman Aide Station (2 events) 2000.00 Cop on Top 10000.00 Underpants Fundraiser 3000.00 Torch Run tshirt sales 2000.00 Roberts Hawaii Bus Pull 2000.00 Individual Contributions 1000.00 Service Clubs Contributions 500.00 Total Program Funding Source (This Page) 33200.00 Total Program Funding Sources for CoH Grant 49200.00 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: SearmA akL(l t 5 (,)e)3i' j4' 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate KONA BREWERS FEST 1000.00 YOUNG BROTHERS GRANT 1000.00 WALMART FOUNDATION 1000.00 Hawaii County GRANT 10,000.00 KUKIO FOUNDATION 1000.00 HAWAII COMMUNITY FOUNDATION 1000.00 VISITOR INDUSTRY CHARITY WALK 1000.00 TOTAL: 16,000.00 Attach additional pages,if needed. - S-e--€ 4-rTA-Ghe J� 6. Explain what plans your agency or program has to increase revenues to support this program: We have 12 fundraisers scheduled for 2021. Some are virtual,which are new for us. We will host a Golf Tournament plus a Bowling Tournament. The community at large is a very giving community,we receive individual donations throughout the year. 7. Program Objectives Using County Nonprofit Grant Program Funds: Special Olympics is planning on 1 State Games travel competition for the 2021 season. We would utilize some of the County of Hawaii grant funds for this competition. Also,we have a storage facility that we pay for monthly that some of the funds would cover. Since we will be doing local competition's,we will purchase ribbons,medals,lei's and postage to mail out awards. We also will be holding a Law Enforcement Torch Run,and will purchase LETR T Shirts to sell as a fundraiser. EXHIBIT A County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: A-1 b wfiC5 i- 4:1-i 8.TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (Le.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 30 Special Olympics Athletes air travel to Fall State Games on Oahu Compete,:Improve motor skills,friendships,training for fdness 30 250 combined Athletes and Volunteers benefit from our program thru Athletic training. Our storage facility houses all SO gear 250 65 Athletes will compete virtually and at State Games:Socializing,friendships,motor skills 65 150 volunteers including SO Athletes will take part in LETR.Outcome;Community friendships,local donations 150 Attach additional pages as necessary. 9.TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 14976.00 14976.00 0.00 Professional Fees 0.00 0.00 0.00 Operations 4500.00 11925.00 4000.00 Supplies 23485.00 8650.00 250.00 Equipment 7795.00 2700.00 250.00 Other: Volunteer T-shirts, meals and recognition 1400.00 750.00 Other: 30 Special Olympics Athletes to State Games 6000.00 4000.00 Other: Air Cargo I Extra Baggage for State Games 200.00 0.00 Other: Fundraising expenses for 12 fundraisers 3345.00 750.00 Other: TOTAL 50756.00 49196.00 10000.00 *If applicable EXHIBIT A County of I3awai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii - - Program Name:' Sf-ec`z -Old,wipcs LAi r in. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ® The Mayor O The Managing Director ® The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest Is defined as:a substantial probability that action taken by on Individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an Industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential • conflicts of interest: if no conflicts exist,check here. ALA 19/1 4 ,•3 C eP ( s : ature of Authoriz d Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: 5PiNM ® tCS 146,^ t- n. 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A • County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name:Special Olympics Hawaii Program Name: we Cs Lk/ b4e� ii.Certification of Understanding (Page 2 of 2) if awarded a grant from the County of Hawaii, I (we)understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly Indicates that the County of Hawai'l Is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from futuresrant participation for a minimum of one year or until a written report Is submitted to.and accepted by,the coundl. i(we)understand there is no provision for further notification to submit the final report.Information and instructions are available at htto://www.hawalicountv.Rov/fn-nonorofit-erant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30,2022 must be returned to the County of Hawel'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding request and may result In actions taken to recover these funds. Awards cannot provide funds for Capital improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 / et/ Signature of Authoriz erson Date PO I D C,N1 F Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Special Olympics Hawaii Program Name: ( 59E-m'l' 06q (41 PtcJ c'` €ST- - i 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 30 Special Olympics Athletes air travel to Fall State Games on Oahu Compete,:Improve motor skills,friendships,training for fitness 30 250 combined Athletes and Volunteers benefit from our program nue Athletic training.Our storage toady houses all SO gear a 250 65 Athletes will compete virtually and at State Games:Socializing,friendships,motor skills 65 150 volunteers including SO Athletes will take part in LETR.Outcome;Community friendships,local donations 150 TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0.00 Professional Fees 0.00 Operations 4000.00 Supplies 250.00 Equipment 250.00 Other: Volunteer T-shirts,meals and recognition 750.00 pecial Olympics Air Fare to State Games Other: S 4000.00 Other: Air Cargo/Extra Baggage for State Games 0.00 Other: Fundraising expenses for 12 fundraisers 750.00 Other: TOTAL 10000.00 Additional Council directives regarding award: EXHIBIT B Teach for America Hawaii Hawaii Island Initiatives 235 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives Agency Director: Jill Murakami Baldemor Phone No.: (8Q19 526 1371 Contact Person: Josh Heimowitz Phone No.: (8019 52a— 1371 Mailing Address: Address: 500 Ala Moana Blvd. Address: Ste. 3-580 City,ST,Zip Honolulu, HI 96813 Facility Address: Address: Address: City, ST,Zip Email Address: josh.heimowitz@teachforamerica.org Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Crowe, LLP Mailing Address: Address: 488 Madison Ave, Floor 3 City,s-r,Zip New York, NY 10022 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 10 Puna 1111 Hamakua 10 North Kona IMI South Hilo IUj North Kohala IUI South Kona ■ North Hilo I UI South Kohala ■1 Ka'u Services or Activities To Be Provided: (One or more can be checked) 1E1 Educational concerns 111 Youth I I Victims of Crimes 1 Culture and the arts I I Aged n Victims of Health or Social Crises U Needs of the poor n Physical/Emotional Disabilities I I Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20 - 21 16,025 20,979 16,250 2. Agency Mission Statement: Teach For America (TFA) finds, develops, and supports a diverse network of leaders who expand opportunity for children from classrooms, schools, and everysector and field that shapes the broader systems in which schools operate. We confront educational inequity through teaching to create a nation free from this injustice. While there are other organizations that train and place teachers, we are the only existing alternative teacher preparation program focusing directly on providing recruitment, certification, and professional development to strengthen the pipeline of teachers and leaders in high-need communities to ultimately create the conditions that ensure lasting student success. Our work is as imperative as ever as the pandemic spotlights the importance of our teachers and schools, especially given its disproportionate impact on the 4,500 students we serve on the island of Hawaii. 3. Program Description: 1) Recruitment (Ho'imi Pono): We find local and diverse leaders to teach on Hawai'i Island. Given the pandemic we are taking a creative approach by leveraging our Corps Member/Alumni (CM/A) network to help us find potential Kama`aina/Native Hawaiian (K/NH) candidates. They can be helpful in connecting us to friends, family, etc., who are upperclassmen at UH Hilo and/or job-seekers in the broader community. 2) CM Leadership Development (Ho'opulapula) this is our national and state accredited alternate route to certification teacher licensing program, comprising intensive teacher development including 1:1 coaching, access to professional learning communities, and on-going teacher development support. 3) Alumni Leadership Development: We are launching a PD cohort for teachers eligible for the Hawaii Certification Institute for School Leaders (HICISL) to support their success in the application process. 4. Total Budget & Position Count: Total Program Budget: 1,196,558 Total Program Position Count: Portion of Total# Total Agency Budget: 3,589,676 Total Agency Position Count: 17 FT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Teach For America National 425,000 Roberts Family Foundation 270,000 Hawaii Department of Education 225,000 Nanea Foundation 75,000 Harold K.L.Castle Foundation 50,000 James McIntosh 25,000 SEE ATTACHED FOR FULL LIST OF DONATIONS TOTAL: 1,156,558 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We rely on continued investment from our individual, corporate, and foundation partners along with public funding from the Hawaii State Legislature, City and County of Honolulu, County of Hawaii, and AmeriCorps. We are fortunate to remain a region supported by TFA National's commitment to native communities, given that we serve a large population of Native Hawaiian children. This policy also ensures at least 2% of new teachers are assigned to work in regions like Hawaii, that serve native children. Because of this dedicated support, all monies we raise in Hawaii stay in Hawaii to directly support our regional work. We continue to work with our board to steward our current donors and work to increase the pool of those who invest in our important work. However, as we look forward to FY22 and beyond, we are deeply concerned about the pandemic's effect on our local economy, and its impact on all fundraising over the next two fiscal years. 7. Program Objectives Using County Nonprofit Grant Program Funds: Recruitment Outcome (HO'imi Pono Initiative): Significantly increase the number of K/NH CM in our incoming corps. CM Leadership Development Outcome (Ho'opulapula Program): K/NH CMs are successful in practice as teacher leaders. Alumni Leadership Development Outcome: Increase the number of alumni making systems change through school and district leadership roles, focusing on our K/NH leaders. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawaii Proposal Revenue Sources TFA National Support $425,000 Roberts Foundation $270,000 Hawai'i Department of Education $225,000 Nanea Foundation $75,000 Harold K. L. Castle Foundation $50,000 James McIntosh $25,000 Zierk Family Foundation $25,000 Americorps $20,000 Sal tchuk $10,000 K.Taniguchi Ltd. $10,000 First Hawaiian Bank $10,000 Bank of Hawaii $10,000 TFA Alumni and Staff Support $1,558 TOTAL $1,156,558 Program Budget 1,196,558 Difference (funding gap) ($40,000) This Request 40,000 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) 1)Recruitment--Ho'imi Pono Initiative: At least ten(10)teachers are accepted for the Ho'opulapula Program At least 10 Teachers will be accepted into the Ho'opuiapula program on Hawaii Island 2)CM Leadership&Development—Ho'opulapula Program--PD Days(per relevant COVID-19 Guidelines) 4 Professional development days with 1 focused on'aina and place. 2)CM Leadership&Development--Ho'opulapula Program--1st and 2nd Year teachers receive an average °.9 at tst and 2nd rear teachers mlt•eeei sono cele wno of pr 5dent er'dslinyalshc, rating of"proficient"or"distinguished by their school administrators on the domains assessed by the Danielson Framework 3)Alumni Leadership Development--alumni and non-TFA teachers participate in leadership development 25%of cur ne verk on Hawaii lslane will pa¢ipate in lcadersttip Cevelopment opeaduni,,es Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages 659,500 40,000 CM and Alumni Support 14,125 0 National Support 435,276 0 Equipment and Supplies 7,378 0 Grants Expense 1,449 0 Other: Postage and Delivery 200 0 Other: Print, Advertising& Media/Subscriptions and Dues 5,400 0 Other: Rent, Utilities, and Occupancy/Depreciation 52,067 0 Other: Telecommunications 7,330 0 Other: Transportation,Meetings & Subsistence 13,833 0 TOTAL 1,196,558 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 401 Ilk , /111 I. A G./telt/Len kitil\fd-Dn 11/7/111 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 5 of 8 County of flawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from futurerant g participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person Date (Eq-e.OALrh ve:D^ir— Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Teach For America Hawaii Program Name: Hawaii Island Initiatives 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1)Recruitment--Ho'imi Pono Initiative: At least ten(10)teachers are accepted for the Ho'opulapula Program A„ea,+o,earners Nmoe accepted n„e,nar 2)CM Leadership&Development--Ho'opulapula Program--PD Days(per relevant COVID-19 Guidelines) Pro,.,—.Idevdepneo,eaYsw.,ee 2)CM Leadership&Development--Ho'opulapula Program--1st and 2nd Year teachers receive an average 90+a o,Ix,and 2rd Year,eac[eswlu'novo rating of"proficient”or"distinguished by their school administrators on the domains assessed by the Danielson Framework 3)Alumni Leadership Development--alumni and non-TFA teachers participate in leadership development TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages 40,000 CM and Alumni Support National Support Equipment and Supplies Grants Expense Other: Postage and Delivery Other: Print, Advertising & Media/d Other: Rent, Utilities & Occupanch Other: Telecommunications Other: Transportation, Meetings qd TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 Volunteer Legal Services Havwai`i Hawaii County Pop-Up Legal Clinics 238 County of Hawaii'i Nonprofit Grant Application lication FY2021-22 p Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics Agency Director: Angela Kuo Min Phone No.: (808)522 —0684 Contact Person: Angela Kuo Min Phone No.: (808)522 —0684 Mailing Address: Address: 545 Queen Street Address: Suite 100 City,ST,zip Honolulu, Hawaii 96813 Facility Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu, Hawaii 96813 Email Address: angela@vlsh.org Fax No.: (808)524 —2147 Accountant/CPA: Joseph Evans Phone No.: (808)763 —8723 Firm (if applicable): Mailing Address: Address: 545 Queen Street Suite 100 city,ST,Zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $17,500 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 121I Hamakua 111 North Kona ® South Hilo n North Kohala INI South Kona 0 North Hilo ® South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns 7 Youth n Victims of Crimes ❑ Culture and the arts Aged ❑Victims of Health or Social Crises ® Needs of the poor ❑ Physical/Emotional Disabilities ❑® Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $6,425 $8,375 $9,375 2. Agency Mission Statement: Volunteer Legal Services Hawaii's ("VLSH") mission is to mobilize the legal community to address the unmet legal needs of the indigent and disenfranchised members of our community. For near 40 years, VLSH continues to be a community based organization with a goal of serving the needs of our community in a responsive and meaningful way. Over 67% of those serviced by VLSH have incomes at or below 125% of the federal poverty guideline for Hawaii. VLSH also provides services to those whose incomes are just above the income cut off for traditional legal aid services (up to the 250% federal poverty line), but do not make enough money to be able to afford a full market rate attorney. In 2020, VLSH conducted over two thousand intakes and provided qualified individuals legal services ranging from legal advice and counsel, limited scope assistance, and referrals to volunteer attorneys for pro bono direct representation. Approximately, 10% of all those serviced through VLSH are from Hawaii County and 27% of all Hawaii Online Pro Bono clients are from Hawaii County. 3. Program Description: Funding will support a series of 8 Pop-Up Legal Advice Clinics in Hawaii County that will provide low- and- moderate income residents to the opportunity to speak with volunteer attorneys on an individual. The Pop-Up Legal Clinic model is based on VLSH's Neighborhood Legal Clinicmodel in which pre-screened individuals are matched with volunteer attorneys for counseling. Participants undergo an intake process which includes the collection of information regarding household income, and legal issue. Additionally, Intake staff collect pertinent facts and documents regarding the specific legal issue to relay to the volunteer attorney with whom the participant is matched with. This in-depth screening process enables volunteers to focus on providing actual legal advice at the clinics and guidance for next steps. Volunteer attorneys are recruited by VLSH and experienced in family law (adoption, guardianship, divorce, child custody, visitation and support); estate planning; probate and trusts; Chapter 7 bankruptcy and consumer debt collections; private residential tenant issues; and VA benefits. VLSH staff will be on-site at each event to oversee logistics and follow-up services for participants in need of further assistance. 4. Total Budget& Position Count: Total Program Budget: $35,000 Total Program Position Count: 1 Total Agency Budget: $542,915 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate The Hawaii State Judiciary-Purchase of Service Contract(not confirmed) $17,500 TOTAL: $17,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Should state funding fall short for the proposed Pop-Up Clinics, Volunteer Legal will seek funding from the Hawaii Justice Foundation to support services to low and moderate income persons in Hawaii County for Calendar Year 2021. 7. Program Objectives Using County Nonprofit Grant Program Funds: By the end of the grant period, Volunteer Legal will have completed 8 Pop-Up Legal Advice Clinics in Hawaii County, serving at least 100 individuals in total. Of the 100 served at the Clinics, an estimated 40 will be provided additional legal assistance by way of limited scope services (i.e. drafting letters to creditors or landlords,completion of court forms, drafting a will, power of attorney, and/or health care directive), and referrals to volunteer attorney for direct services (negotiating with opposing party, attending court hearings, and full representation). The Pop-Up Legal Clinics will be held in rural districts with high poverty rates. Volunteer Legal plans to hold "Pop-Ups" around the island rotating different cities each time to reach the most residents possible. The proposed Pop-Up Legal Clinics will enhance current services offered to Hawaii County Residents through Volunteer Legal's core services and the Hawaii Online Pro bono legal advice portal. Those residents who cannot make it to an in-person clinic will have the same opportunity to speak with an attorney over the phone for 45-60 minute customized advice and counsel session. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 r County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) At least 100 individuals will be provided legal advice at the 8 Pop-Up Clinics 100 Clinic Participants Of the estimated 100 clinic participants,40 will be provided further assistance 40 Additional Services Beyond Clinic Services 8 Pop-Up Legal Clinics will be presented in Hawaii County without fee to the public 8 Total Pop-Up Legal Clinics Attach additional pages as necessary. 9. TABLE II: FY 20-21 FY 21-22 FY 21-22 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $395,914 $11,500 Professional Fees 37,000 0 Operations 86,541 2,000 Supplies 3,750 500 Equipment 9,320 1,500 Other: Airfare, Mileage and Parking 500 1,000 Other: Venue Rental Fees 500 500 Other: General Liability/Professional Liability Insurance 8,890 500 Other: Event Refreshments for Volunteers and Participahh 500 0 Other: TOTAL $542,915 $17,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 10. ORGANIZATION CONFLICT JASCLOSURE F*RM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Angela Kuo Min POSITION: Executive Director. May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council n The Mayor The Managing Director I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ix I If no conflicts exist, check here. Signature of Authorized Per sq/(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 11. Certification of Understanding (Page 1of2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 11. Certification of Understanding (Page 2 of 2). If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of/(tI orized Person 1 Date Executive Director Title/Position of Authorized Person EXHIBITA NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result At least 100 individuals will be provided legal advice at the 8 Pop-Up Clinics 100 Clinic Participants Of the estimated 100 clinic participants,40 will be provided further assistance 40 add'I partcipants 8 Pop-Up Legal Clinics will be presented in Hawaii Countywithout fee to the public 8 Total Pop-Up Legal Clinics TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $11,500 Professional Fees 0 Operations 2,000 Supplies 500 Equipment 1,500 Other: Airfare,Milage,and Parking 1,000 Other: Venue Rental Fees 500 Other: General Liability/Professional Liability Insurance 500 Other: Event Refreshments for Volunteers and Participants 0 Other: TOTAL $17,500 Additional Council directivesregarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 West Hawaii Community Health Center; Inc. (WHCHC) Dental Expansion for Low Income in South Kona 239 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona Agency Director: Richard Taaffe Phone No.:(808 ) 326 —3884 Contact Person: Natasha Ala - _ Phone No.:(808 ) 938 —1699 Mailing Address: Address: 75-5751 Kuakini Hwy., Suite 203 Address: city,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: same Address: City,ST,Zip Email Address: nala@westhawaiichc.org Fax No.: (808 ) 334 —2190 Accountant/CPA: Diane Pautz Phone No.:(808) 326 —3883 Firm (if applicable): Mailing Address: Address: 75-5751 Kuakini Hwy., Suite 203 City,ST,Zip Kailua Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ■I South Kona ❑ North Hilo ❑South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑� Youth ❑Victims of Crimes ❑ Culture and the arts 0 Aged ❑Victims of Health or Social Crises El Needs of the poor ❑ Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $22,675- $29,086 $27,614 2. Agency Mission Statement: • The mission of West Hawaii Community Health Center is to offer quality, comprehensive and integrated health services accessible to all who pass through our doors, regardless of their ability to pay.We promote improved health and well-being through ho'ola kino-healing on individuals,families and communities.Our vision is to live in a health community,woven like lauhala, nurtured by strong,productive individuals and-families. Ua mau-unending continuation. WHCHC was established as a non-profit 501 (c)3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later, in 2006,WHCHC received its Federally Qualified Health Center(FQHC) status, paving the way for a cost-effective approach to delivering health care to the under-served and uninsured in our community. Since 2006,WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages, cultures,and income levels.We have achieved this by offering comprehensive medical,dental,and behavioral health services as well as enabling services.Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured, and low income people;referral services to specialists;assistance with prescription medications; language interpretation and translation services;care coordination for patients with chronic illnesses;and Health Education and Community Outreach Programs. 3. Program Description: The WHCHC Dental Program is the only safety-net dental program in West Hawaii providing comprehensive dental care for low-income adults and children.With community support from the Hawaii Dental Service Foundation,the Office of Family Services,Head Start, Early Head Start, Perinatal Consortium,Office of Social Ministry, Hawaii County Council Representatives,the March of Dimes,and the Hawaii Island Oral Health Coalition,funds were raised to help WHCHC open the Keiki Dental clinic in Kealakekua, in April of 2009. During our first year of providing keiki dental services, roughly 300 of patients were referred, and seen, in the Kona Community Hospital operating room for comprehensive dental treatment under full anesthesia because their oral was so poor and had gone untreated.The condition of children's oral health was heartbreaking! Over the past 12 years we have seen drastic improvement in keiki oral health as WHCHC dental has expanded the program and opened additional clinics in Kealakehe and Wiakaloa. Responding to the critical need for adult dental care in West Hawaii, in 2009 WHCHC began an adult emergency dental program in Kailua Kona.This program was operated from a mobile dental clinic located at the homeless shelter. Due to limited payment reimbursement options,adult dental treatment at the mobile dental clinic was limited to emergency dental care only. In the summer of 2016 WHCHC received a HRSA Oral Health Expansion award which paved the way for providing comprehensive adult dental care in West Hawaii.WHCHC currently provides adult dental services at our clinics in Kealakehe and Wiakoloa.WHCHC is currently on schedule to open an expanded dental clinic in Kealakekua,which will allow us to serve adults and more keiki in Kealakekua in South Kona.This new clinic will open in spring 2021. 4.Total Budget & Position Count: Total Program Budget: 0 Total Program Position Count: 34 Total Agency Budget: $25,470,000 Total Agency Position Count: 207 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Hawaii County Nonprofit Grant $20,000 TOTAL: $20,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Funds requested with this proposal are a one-time expense needed to open the new facility.Once the new expanded dental clinic in Kealakekua is open and fully operational it will generate enough revenue to pay for the continuation of the program supplies. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funds requested through this proposal will not be used for the construction,or any part of the Kealakekua Dental clinic build. Funds requested through this award are needed for the one-time expense of purchasing hand tools and dental supplies for the new dental clinic.Once the Kealakekua Dental facility is completed,and fully operational, it will include a staff of 3 dentists and 2 hygienists, along with all necessary support staff.WHCHC anticipates serving roughly 5,000 patients and providing 12,960 annual dental encounters for keiki and adults.WHCHC is the only safety-net organization providing comprehensive medical,dental and behavioral health care services to the most vulnerable and under-served populations in West Hawaii. WHCHC believes that oral health and systemic health are interrelated in that overall health includes oral health.As an integrated primary health care organization,our medical providers work closely with our dentists and the behavioral health team, engaging in an inter-professional collaboration exchanging meaningful information for the purpose of treating the whole person.This integrated model of care also extends to our enabling staff (Care Coordination Department, Patient Navigators, Community Health Workers, Health Educators, Eligibility Technicians, Insurance Enrollment Specialists)all of whom work with the providers and clinical staff to deliver optimal,wrap-around patient care. By improving oral health outcomes for the most disadvantaged keiki and adults in our community,WHCHC will: • Reduce costs associated with emergency department visits for preventable oral health problems. • Reducing cost for restorative treatment by addressing teeth damage early. • Improve self-esteem, employability, decrease absenteeism (work/school),and improve mental health of target 000ulation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeosuring what happens for the Participants after they have participated in your program?Describe,be specific.) Operatory 1:Restorative 7 encounters per day Operatory 2:Emergency/light procedures/hygiene 7 encounters per day Operatory 3:Hygiene 6+/-encounters(adult)per day Operatory 4:Hygiene 10+/-encounters(keiki)per day Operatory 5:Restorative 7 encounters per day Operatory 6:Hygiene 10+/-encounters(keiki)per day Operatory 7:Restorative 7 encounters(adult)per day Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 _ Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $20,000 $20,000 Equipment Other: Other: Other: Other: Other: TOTAL 0 $20,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑� Staff appointed by a member of the Council ❑ The Mayor 01 The Managing Director ❑ The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. 1/27/2021 Signature of Authorized Per. •n ( (ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting,-and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/27/2021 Signature of Auth.rized P= s n Date Richard Taaffe, CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Program Name: Dental Expansion for Low Income in South Kona 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 West Hawaii Community Health Center Inc. (WHCHC) Outreach to Vulnerable Populations Program 240 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:West Hawaii Community Heath Center Inc. Program Name:Outreach to Vulnerable Populations Program Agency Director: Richard Taaffe Phone No.:(808 ) 326 —3884 Contact Person: Natasha Ala Phone No.:(808 ) 938 —1699 Mailing Address: Address: 75-5751 Kuakini Hwy., Suite 203 Address: City,ST,Zip Kailua Kona, HI 9674 Facility Address: Address: same Address: City,ST,Zip • Email Address: nala@westhawaiichc.org Fax No.: (808 ) 334 —2190 Accountant/CPA: Diane Pautz Phone No.:(808) 326 —3883 Firm (if applicable): Mailing Address: Address: 75-5751 Kuakini Hwy., Suite 203 City,ST,Zip Kailua Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua 0 North Kona ❑South Hilo ❑ North Kohala El South Kona ❑ North Hilo South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns EJ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged Q Victims of Health or Social Crises ❑� Needs of the poor Physical/Emotional Disabilities ■❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $22,675 $29,086 $27,614 2. Agency Mission Statement: The mission of West Hawaii Community Health Center is to offer quality, comprehensive and integrated health services accessible to all who pass through our doors,regardless of their ability to pay.We promote improved health and well-being through ho'ola kino-healing on individuals,families and communities.Our vision is to live in a health community,woven like lauhala, nurtured by strong,productive individuals and families. Ua mau-unending continuation. WHCHC was established as a non-profit 501 (c)3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later, in 2006,WHCHC received its Federally Qualified Health Center(FQHC) status, paving the way for a cost-effective approach to delivering health care to the under-served and uninsured in our community. Since 2006,WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages, cultures,and income levels.We have achieved this by offering comprehensive medical,dental,and behavioral health services as well as enabling services. Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured, and low income people;referral services to specialists;assistance with prescription medications; language interpretation and translation services;care coordination for patients with chronic illnesses;and Health Education and Community Outreach Programs. 3. Program Description: The Health Education and Community Outreach Program supports under-served and vulnerable populations such as the Marshallese,the Micronesians, Native Hawaiians,the Spanish speaking community,and disadvantaged youth groups by connecting these populations with resources and opportunities that will result in strengthening their community ties and promote community wellness. By addressing upstream issues and working to improve social determinants of health (SDOH)facing the most under-served populations in West Hawaii,WHCHC improves community well-being and decrease health disparities among low income and under-served populations. Outreach to Vulnerable Populations Program provides the following services to the community: 1.WHCHC staff members participate regularly at community health screenings and health education opportunities to promote and inform the public about personal health and disease prevention. Educational materials are provided in English,as well as other languages including:Spanish, Marshallese, and Ilocano/Tagalog. In addition,WHCHC has a multi-lingual staff fluent in English,Spanish and Marshallese. 2.WHCHC staff provide health education and training classes at public housing facilities,senior day care centers, homeless shelters, at public schools,churches,night clubs,in the coffee fields,and many other community gathering locations. 3.WHCHC staff collaborates with community leaders from the Marshallese community, Micronesian community,the Spanish speaking community,the farm working community,the LGBT community,and many others to develop trusted relationships and work as partners in supporting and promoting the health and well-being of each community. 4. Total Budget& Position Count: Total Program Budget: 0 Total Program Position Count: 6 Total Agency Budget: $25,470,000 Total Agency Position Count: 207 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Currently WHCHC is seeking funding support through grants to help cover program cost for the Health Education and Community Outreach Program Hawaii County Nonprofit Grant $20,000 TOTAL: $20,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: WHCHC will continue to develop diverse sources of revenue to fund and support the Outreach to Vulnerable Populations Program. Currently the services provided through this program are not billable services and thus WCHCH must rely on private foundations,government support,and donor contributions to fund these valuable public services. 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used for the printing and purchase of health educational materials(in multiple languages)to be distributed at public housing facilities,churches, and on line health education training classes. Much of the health education and outreach will focus on the efficacy of getting vaccinated from COVID-19.of The West Hawaii Community Health Center service area extends from Kawaihae to Ocean View,an area of roughly 80 miles-funds will be used to pay for staff to travel to locations through out this vast service area where health education opportunities are limited.Funds will also be used to purchase medical supplies to be used for health screenings at public housing,schools and other community locations.Through the support of Hawaii County,the WHCHC's Outreach to Vulnerable Populations Program will reduce the social determinants that contribute to the disparities facing many of the under-served populations,thereby creating more productive and rewarding lives of our minority and youth populations in West Hawaii.Studies show that health does not occur in a vacuum.Instead, health status is embedded in larger living and working conditions.There is strong,suggestive evidence that viewing an individual as more than just a system of organs,and taking into account the social context in the delivery of healthcare services can have an important impact on improving health.There is growing evidence that the social determinants that negatively impact these under-served populations are costly to society in multiple ways.Through this generous County Nonprofit grant,WHCHC will support under-served populations in West Hawaii by helping them become proactive in promoting their own health and wellbeing and connecting vulnerable populations with primary health care services(medical,dental,and behavioral health),thus reducing costly ER visits and specialized treatments. In addition,a significant focus will be placed on promoting vaccination among high-risk 000ulations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) • WHCHC Outreach staff will do in person health screening&health education to individuals 2,800+people will be reached WHCHC Outreach staff will provide health education training to community groups 250+people will receive specialized training WHCHC Outreach staff will support public health through promoting and assisting covid vaccinations efforts 20,000 high-risk individuals in West Hawaii Attach additional pages as necessary. 9. TABLE II: . - PROGRAM EXPENDITURES FY 20-21 FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $10,000 $15,000 $15,000 Equipment $3,000 $3,000 Other: mileage $1,989 $2,000 $2,000 Other: Other: Other: Other: TOTAL $11,989 $20,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021 -2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): [❑ Member or members of the Council i❑ Staff appointed by a member of the Council �❑ The Mayor ❑l The Managing Director The Director of Finance ❑n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 7'2/- 1/27/2021 Signature of Authorized P n (specify title) Date EXHIBIT A .NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 11. Certification of Understanding (Page sof 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/27/2021 Signature of Autho ized P rson Date Richard Taaffe, CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Heath Center Inc. Program Name: Outreach to Vulnerable Populations Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 21-22 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8 West Hawaifi Community Health Center, Inc. (WHCHC) Street Medicine - Homeless Outreach Program 241 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name:West Hawaii Community Health Center Inc. Program Name:Street Medicine - Homeless Outreach Program Agency Director: Richard Taaffe Phone No.:(808 ) 326 —3884 Contact Person: Natasha Ala Phone No.:(808 ) 938 —1699 Mailing Address: Address: 75-5751 Kuakini Hwy., Suite 203 Address: City,sT,Zip Kailua Kona, HI 96740 Facility Address: Address: same Address: City,ST,Zip Email Address: nala@westhawaiichc.org Fax No.: (808 ) 334 —2190 Accountant/CPA: Diane Pautz Phone No.:(808) 326 —3883 Firm (if applicable): Mailing Address: Address: same City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) l Puna Hamakua 0 North Kona ❑South Hilo n North Kohala ■(South Kona ❑ North Hilo South Kohala 0Ka1.1 Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth I Victims of Crimes ❑ Culture and the arts El Aged Victims of Health or Social Crises ❑� Needs of the poor ❑� Physical/Emotional Disabilities O Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name: Street Medicine - Homeless Outreach Program - - 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 18-19 FY 19-20 FY 20-21 $22,675 $29,086 $27,614 2.Agency Mission Statement: The mission of West Hawaii Community Health Center(WHCHC)is to offer quality,comprehensive and integrated health services accessible to all who pass through our doors, regardless of their ability to pay.We promote improved health and well-being through ho'ola kino-healing on individuals,families and communities. Our vision is to live in a health community,woven like lauhala,nurtured by strong, productive individuals and families. Ua mau unending continuation. WHCHC was established as a non-profit 501 (c)3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later,in 2006,WHCHC received its Federally Qualified Health Center(FQHC) status,paving the way for a cost-effective approach to delivering health care to the under-served and uninsured in our community. Since 2006,-WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages, cultures,and income levels.We have achieved this by offering comprehensive medical,dental,and behavioral health services as well as enabling services.Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured, and low income people;referral services to specialists;assistance with prescription medications;language interpretation and translation services;care coordination for patients with chronic illnesses;and Health Education and Community Outreach Programs. 3. Program Description: To respond to the profound health and social needs of the homeless population,especially during COVID 19,WHCHC will enhance our street medicine efforts by increasing the frequency and duration of outreaches in Kona town proper,as well as HOPE Services and County facilities,including the shelter and the microunits. WHCHC is committed to enhancing the overall health of the community of West Hawaii. Being the only health center in the area providing services regardless of a person's ability to pay.We serve the most vulnerable population, including the homeless population.There are many barriers to serving the homeless.We have overcome a majority by providing"street medicine,"an outreach where individuals receive medical, behavioral health (BH), addiction and social service intervention delivered by an integrated treatment team that includes medical and BH providers, case managers, RNs, and enrollment specialists.The team frequents encampments like the Currently WHCHC's outreach is only once a month for three hours.We seek to expand this effort to improve the health outcomes of our homeless population,provide COVID 19 health education and support, increase inter-agency collaboration,and encourage harm reduction. COVID 19 has reaffirmed the vital significance of interagency collaboration.We plan to respond to this need by hosting case reviews for high-risk individuals, participating in community task forces that address homelessness,and increasing daily communication between our staff and the community resources that our patients frequently engage with. Case reviews will include WHCHC, HOPE Services,HPD, EMS,and other agencies that support homeless individuals. In 2019 WHCHC had 625 unduplicated patients self identified as being homeless. 4. Total Budget& Position Count: Total Program Budget: 0 Total Program Position Count: 15 Total Agency Budget: $25,470,000 Total Agency Position Count: 207 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 2 of 8 County, of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name: Street"Medicine Homeless Outreach Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY21-22 Revenue Source Estimate Hawaii County Nonprofit Grant $10,000 TOTAL: $10,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Sustainability can be achieved through billing health insurances for medical and BH appointments.At present,WHCHC's billing team is exploring how to bill appointments that are not on-site at the health center. During the next six months,we will continue to investigate and streamline billing processes to ensure the outreaches continue indefinitely. WHCHC has been operating the Street Medicine Outreach program for the past 5 years through public/private donations and time volunteered to the program by WHCHC staff who participate in the Street Medicine Program outside their regular assigned duties at WHCHC. With this proposal WHCHC is requesting$10,000 to be used for health screening supplies and equipment needed to provide medical triage care at homeless encampments and the streets of North/South Kona. Funds will also be used to provide hygiene supplies and transportation if needed to get injured and ill to the clinic for follow-up appointments. 7. Program Objectives Using County.Nonprofit Grant Program Funds; Goal 1:WHCHC's street medicine outreach(SMO)team will engage with 360 individuals who are experiencing homelessness •During the weekly SMO,the team will provide medical, behavioral health,or social services intervention to at least five individuals a week •During the weekly SMO,the team will engage with at least 15 individuals a week to discuss health,services,etc.and build rapport •Outside of the SMO, BHCMs will provide an additional five hours of social service and health intervention to individuals experiencing homelessness each week •BHCMs will keep a registry of individuals who they provide intervention to as a result of the SMO Goal 2:WHCHC will increase inter-agency collaboration with HOPE Services,the County,and other agencies that work with the homeless population. •WHCHC BHCMs will participate in monthly homeless task force meetings •WHCHC BHCMs will host monthly case review meetings for high-risk individuals •WHCHC will publicize SM outreaches through the WHCHC marketing and development department. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name: Street Medicine - Homeless Outreach Program 8. TABLE I: What are the measurable performance outcomes that would be achieved with this funding? PROGRAM-PERFORMANCE OUTCOMES (i.e.:How are youmeasuring what happens for the Participants after they have participated in your program?Describe,be specific.) WHCHC's street medicine outreach(SMO)to individuals experiencing homelessness Engage and provide care for 350 individuals WHCHC will increase inter-agency collaboration in serving the homeless in West Hawaii Engage new partners in monthly outreach WHCHC will participate in community homeless task force meetings in the county WHCHC staff will attend monthly meetings WHCHC will provide referrals to homeless for emergency dental services WHCHC staff will track#of refers for emergency dental WHCHC will provide referrals to homeless for substance use disorder treatment in clinic WHCHC staff will track#of referrals for Substance use disorder treatment Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY zo-zs FY 21-22 FY 21-22 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $10,000 $10,000 Equipment Other: Other: Other: Other: Other: TOTAL 0 $10,000 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name:Street Medicine - Homeless Outreach Program 10.- ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): U Member or members of the Council [ 0 Staff appointed by a member of the Council L1 The Mayor 0 The Managing Director l The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, anyconflicts or potential conflicts of interest: pI If no conflicts exist, check here. 1/27/2021 Signature of Authoriz d Pero (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name: Street Medicine - Homeless Outreach Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood allof the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the programs) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendorsehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name: Street Medicine - Homeless Outreach Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the,grant period (must be refunded.to County) and exclusion from future grant participation fora minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available athttp://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2022 must be returned to the County of Hawai'i with the final report. Failure to,return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1/27/2021 Sign‘ture of Authorized P-rson % Date Richard Taaffe, C 0 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2021-2022 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2021-22 Agency Name: West Hawaii Community Health Center Inc. Program Name: Street Medicine - Homeless Outreach Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 21-22 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2020-2021 Page 8 of 8